Bilateral Ureteral Reimplantation Research Articles

V04-05 ROBOT-ASSISTED LAPAROSCOPIC EXTRAVESICAL BILATERAL URETERAL REIMPLANTATION: LUAA TECHNIQUE

You have accessJournal of UrologyCME1 Apr 2023V04-05 ROBOT-ASSISTED LAPAROSCOPIC EXTRAVESICAL BILATERAL URETERAL REIMPLANTATION: LUAA TECHNIQUE Parviz Hajiyev, Jared Fialkoff, and Mohan Gundeti Parviz HajiyevParviz Hajiyev More articles by this author , Jared FialkoffJared Fialkoff More articles by this author , and Mohan GundetiMohan Gundeti More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003252.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In today's era of minimally invasive surgery, robotic-assisted laparoscopic ureteral reimplantation (RALUR) is being popularly performed at many centers. We previously described the LUAA technique (Eur Urol 2016; 70(5):818–823). METHODS: Through this video, 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. A 4 years old girl presented with recurrent urinary tract infections (UTI) . Her voiding cystourethrogram (VCUG) was suggestive of bilateral high grade of vesicoureteric reflux (VUR), and DMSA scan showed multiple scars. RESULTS: For this persistent bilateral VUR with breakthrough UTIs beyond the age of toilet training, she underwent a robotic-assisted laparoscopic ureteric reimplantation- bilateral (RALUR-b) by the “LUAA” technique. CONCLUSIONS: Postoperative she had USS one month and one year and was normal. The VCUG at 4 months showed resolved VUR bilateral. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e339 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Parviz Hajiyev More articles by this author Jared Fialkoff More articles by this author Mohan Gundeti More articles by this author Expand All Advertisement PDF downloadLoading ...

V01-11 ROBOT-ASSISTED BILATERAL URETERAL RE-IMPLANTATION AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER FOR DISTAL URETERAL FIBROSIS

You have accessJournal of UrologyCME1 Apr 2023V01-11 ROBOT-ASSISTED BILATERAL URETERAL RE-IMPLANTATION AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER FOR DISTAL URETERAL FIBROSIS Gabriel Frölicher, Christoph Schregel, Yasmin Trachsel, Tutal Mustafa, and Hubert John Gabriel FrölicherGabriel Frölicher More articles by this author , Christoph SchregelChristoph Schregel More articles by this author , Yasmin TrachselYasmin Trachsel More articles by this author , Tutal MustafaTutal Mustafa More articles by this author , and Hubert JohnHubert John More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This video presents the surgical technique of robot-assisted ureteral re-implantation for distal ureteral fibrosis after open cystectomy and reconstruction with Studer orthotopic neobladder. A 59-year-old patient underwent open radical cystectomy and orthotopic urinary diversion for muscle-invasive bladder cancer. Postoperatively, left hydronephrosis and pyelonephritis occurred. Antegrade attempts to place an ureteral stent were unsuccessful. A nephrostomy drain was placed in the left side. The patient was then referred for laparoscopic robotic reconstruction. METHODS: The ports were placed in analogy to robot-assisted cystectomy. First an extended adhesiolysis was necessary. The intestinal loops were dissected guided by concomitant cystoscopy which revealed the borders between intestine and bladder wall. Finally, right ureter was identified in the proximity of the afferent loop of the Studer neobladder. After preparing and freeing, the right ureter was intubated with a Ch.8 mono-J catheter. The search for the left ureter continued. The left ureter was localised using Methylene blue applied antegrade by the nephrostomy tube. Several attempts to intubate the left ureter Ch.8 mono-J were frustrane due to the considerable long stricture. Further dissection into the retroperitoneal space was necessary. The ureter seemed totally fibrotic over several centimetres. Finally antegrade left ureteral catheterization and retrograde insertion of a Ch.8 mono-J catheter was successful. Accidental lesions of the afferent loop were closed with a 4-0 PDS suture. The ureters were re-implanted end-to-side with 4-0 Stratafix® running sutures. RESULTS: The patient was discharged on the 7th postoperative day after testing the uretero-neobladder anastomosis through a pouchography and a retrograde ureteropyelography and after removal of both mono-J stents. No perioperative complications were observed. Furthermore, the left renal function showed an increasing function 1 year postoperatively in the renal scintigraphy. CONCLUSIONS: This demanding robotic reconstructive ureteral re-implantation so far shows the feasibility and the clinical value of robotic minimal invasive approaches even in complex reconstructive surgeries after open urinary diversion. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e83 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gabriel Frölicher More articles by this author Christoph Schregel More articles by this author Yasmin Trachsel More articles by this author Tutal Mustafa More articles by this author Hubert John More articles by this author Expand All Advertisement PDF downloadLoading ...

Bilateral Lumbar Erector Spinae Plane Block for Pain Control in Open Ureteric Repair and Reimplant: A Case Report

Introduction: Lower abdominal surgery often leads to severe postoperative pain and challenge for anesthetists regarding its management. A multimodal approach with regional anesthesia techniques might be an opportunity. Erector spinae plane block (ESPB) is usually used for pain management in thoracic and abdominal surgery. New surgical indications are increasingly suggested for lumbar ESPB (spine and urological surgery) both in pediatric and adult procedures. In this case report, we present the results of the fascial block at the lumbar spine in an adult patient for lower abdominal surgery. The purpose of this procedure is to offer the patient an alternative to neuraxial anesthesia/analgesia and opioid-sparing anesthesia. Case Presentation: Bilateral lumbar ESPB in a 46-year-old female patient scheduled for bilateral open ureteral reimplantation surgery after iatrogenic injury was performed at the Civil Hospital of Teramo in Italy (January 2022). Postoperative pain evaluation reported a substantial absence of pain. The patient was promptly mobilized, and the postoperative course was free of complications. There was no additional opioid administration. Conclusions: To the best of our knowledge, this has been the first described lumbar ESPB case for intraoperative and postoperative analgesia in adult bilateral ureters replacement and reimplantation after iatrogenic injury. We suggest bilateral lumbar ESPB, as already reported for numerous lower abdominal surgeries, as a valid alternative in perioperative pain management in adults’ ureteral reimplant.

Multidisciplinary minimally-invasive approach to complex vesicovaginal fistula repair

This video's objectives are to demonstrate the techniques and decision process used in the approach to a complex vesicovaginal fistula resulting from obstetric injury, after previous attempts at repair had failed. Our patient was referred from an outside institution to us. At emergent cesarean delivery at 24 weeks, hemoperitoneum, uterine rupture, and placenta percreta were found. During hysterectomy, the right ureter was ligated and the posterior wall of the bladder sustained large cystotomies. Urology repaired the injury, reimplanted the ureter, and placed a right ureteral stent, but the patient developed a vesicovaginal fistula and left ureteral obstruction. Ten months after diagnosis, it was repaired using a robot-assisted laparoscopic approach. This required bilateral ureteral re-implantation and omental flap. Unfortunately, this repair broke down, and testing was concerning for vesicovaginal and left ureterovaginal fistula, high at the vaginal apex. The patient was referred to our institution for our attending surgeon's expertise in fistula repair. Takeaways from this video presentation include: careful delineation of genito-urinary anatomy, vaginal approach, optimization of visualization, wide mobilization of tissue around the defect, watertight closre, meticulous multilayer closure, and aggressive management of infection.

Bilateral ureteral reimplantation at complete primary repair of exstrophy: Post-operative outcomes

The value of bilateral ureteral reimplant (BUR) at the time of complete primary repair of bladder exstrophy (CPRE) has been suggested, however, outcomes are poorly characterized in current medical literature. We hypothesize that BUR at time of CPRE will decrease the rate of recurrent pyelonephritis, post-operative vesicoureteral reflux (VUR), and the need for subsequent ureteral surgery. We analyzed 64 consecutive patients with a diagnosis of classic bladder exstrophy (BE) who underwent CPRE at three institutions from 2013 to 2019.15 patients underwent cephalotrigonal BUR-CPRE and 49 patients underwent CPRE alone. Our primary outcome was >1 episode of pyelonephritis as documented in the medical record. Secondary outcomes were persistent vesicoureteral reflux (VUR), with a sub-analysis of number of refluxing renal units and presence of dilating VUR, and the need for subsequent ureteral surgery. Descriptive statistics in addition to standard, two tailed univariate statistics, were used to compare the groups where appropriate. BUR-CPRE was associated with a significant decrease in the rates of post-operative VUR, number of refluxing renal units, and need for subsequent ureteral surgery (p=0.002, p=0.001, and p=0.048 respectively). There was a reduction in the rates of recurrent pyelonephritis and dilating reflux in patients undergoing BUR-CPRE, though it did not reach significance. Female gender was significantly associated with recurrent pyelonephritis regardless of BUR-CPRE status (p=0.005). There were no reports of distal ureteral obstruction or other complications following BUR-CPRE. The mean post-operative follow up for the BUR-CPRE group was 46.33 (10.26) months vs. 53.76 (26.05) months for CPRE (p=0.11). Recurrent pyelonephritis following bladder closure in patients with BE is a well-documented surgical complication, with centers performing CPRE reporting rates of post-operative pyelonephritis from 22 to 50%. Our series demonstrates similar efficacy of BUR-CPRE compared to other contemporary series and provides additional detail about need for subsequent ureteral surgeries and increased long term follow-up of these complex patients. Limitations of the study include male predominance of the cohort and lack of randomization of BUR-CPRE. BUR-CPRE decreases postoperative VUR and the need for additional ureteral surgery in select BE patients; it should be considered when technically feasible. While results continue to suggest a trend toward decreased recurrent pyelonephritis and dilating reflux, further longitudinal follow-up in our cohort will be needed.

Anaesthetic Management in a Child with Cutis Laxa for Bilateral Ureteric Reimplantation

Cutis laxa is a rare congenital multisystem connective tissue disorder. Patients with cutis laxa can present with distinctive facial features, pulmonary emphysema and right-sided heart failure. Anaesthetic management is important because of difficult airway and respiratory/cardiac abnormalities. We have reported the preoperative evaluation and anaesthetic management of a child with Cutis laxa with right cleft lip and palate.

Understanding an unusual urothelial disorder: cystitis cystica et glandularis

Objectives: To study the presentation and natural course of cystitis cystica et glandularis. Methods: A retrospective analysis of patients with histopathologically confirmed cystitis cystica et glandularis from March 2016 to March 2018 who at least completed their 2 years’ follow-up was performed. Perioperative details along with the last available follow-up were included in the analysis. Results: A total of 10 patients were included. The mean age (± standard deviation) was 33.4 (±14.0) years and nine (90%) were men. The most common presentation was storage and voiding lower urinary tract symptoms (80%) along with haematuria (40%) and dysuria (20%). Four patients had the presence of hydronephrosis in preoperative imaging, of which three patients had bilateral mild hydroureteronephrosis. All the patients underwent transurethral resection of the bladder tumour as all were diagnosed with urinary bladder mass on preoperative imaging. All the patients had a trigonal lesion with a bullous appearance partially obstructing the bladder neck. Six patients underwent double J stenting in the perioperative period. The mean (± standard deviation) follow-up duration was 32.8 (±7.5) months. Patients were kept on regular surveillance with imaging and cystoscopy as indicated. Eight patients (80%) developed recurrence in the follow-up period. The mean number of recurrences was 1.5 (±1.1). One of the patients had to undergo augmentation ileocystoplasty with bilateral ureteric reimplantation because of the recurrent lesion with small contracted bladder, while another patient underwent cystectomy with urinary diversion owing to recurrence and refractory lower urinary tract symptoms. Besides, there was no evidence of malignancy after this entity in any of the patients. Conclusion: Cystitis cystica et glandularis is a rare clinic pathological entity which often mimics bladder tumour. Cystitis cystica et glandularis is common in men and often presents with lower urinary tract symptoms. Transurethral resection forms the mainstay of treatment. However, it is often associated with upper tract hydronephrosis. Its controversial premalignant nature compounded with recurrence and risk of upper tract deterioration warrants close surveillance. Level of evidence: 4

Augmentation Cystoplasty in Children: Institute of Kidney Diseases Peshawar Experience

Objective: The aim of this study is to share our single-center experience of Augmentation Cystoplasty (AC) in children regarding indications, bowel segment used, associated procedures, and its complications. Materials and Methods: We analyzed data of all pediatric patients who underwent AC at Institute of Kidney Diseases (IKD), Peshawar between July 2017 and March 2020. Results: A total of 18 pediatric patients are included in the study who underwent Bladder augmentation (BA) either isolated in 1 (5.5%), or along with other associated procedures like Mitrofanoff 17 (94.4%), Antegrade Continent Enema (ACE) 6 (33.3%), Bladder Neck Reconstruction (BNR) 5 (27.7%) and Bilateral ureteric Re-implantation (B/L UR) in 3 (16.6%). Indication for Bladder augmentation were Neurogenic bladder (NGB) 13 (72.2%), Exstrophy Epispadias Complex (EEC) 3 (16.6%) and Posterior urethral value with small functional capacity bladder 2 (11.1%). Small gut used in 15 (83.3%) and large gut in 3 (16.6%) for BA. For Mitrofanff associated with bladder augmentation, Appendix was used in 14 (82.35%) and small gut (Monti) in 3 (17.6%) cases. For ACE associated with BA, in 4 (66.6%) Appendix used as right-sided ACE and in 2 (33.3%) small gut (Monti) as left-sided ACE. No intraoperative complications noted, while early post-op complications, 2 wound infection and 1 urinary leakage from wound, were noted in 3(16.6%) cases and late post-op complications (stomal stenosis) in 4(22.2%) patients.

Impact of bilateral ureteral reimplantation at the time of complete primary repair of bladder exstrophy on reflux rates, renogram abnormalities and bladder capacity

Bilateral ureteral reimplantation at the time of the complete primary repair of bladder exstrophy (BUR-CPRE) has been proposed and has demonstrated favorable outcomes in the past. However, the potential benefits, including prevention of vesicoureteral reflux (VUR) and renal scarring must be tempered with any risks of reimplantation, persistent VUR, and the potential for overtreatment. We aimed to determine the impact of BUR-CPRE on reflux rates, renogram findings and bladder capacity. An IRB approved registry of children treated for bladder exstrophy epispadias complex (BEEC) during a long-term international collaboration hosted in a region with high prevalence of BEEC was queried. Children undergoing primary CPRE for bladder exstrophy (BE) were identified. Surgical procedure and outcome measures nuclear medicine dimercaptosuccinic acid (DMSA) scintigraphy scans, voiding cystourethrogram (VCUG), and urodynamic study (UDS) were assessed for presence and degree of VUR, renogram abnormalities, and bladder capacity. A total cohort of 147 patients with BEEC was queried; 52 children (37 males, 71%) underwent primary CPRE for BE between 2009 and 2019at median age of 1.1 years (IQR 0.6-1.9 years) with median follow up 4.4 years (IQR 2.4-6.4 years). BUR-CPRE was performed in 22/52 (42%). After BUR-CPRE, children were less likely to have VUR (any VUR present in 9 of 20 with imaging (45%) compared to 23 of 26 with imaging (82%) in the CPRE alone group (p=0.007)). VUR in the BUR-CPRE group tended to be unilateral and lower grade in comparison to the CPRE alone group. DMSA abnormalities were less common in the BUR-CPRE group (4/19 (21%) vs.12/27 (44%)), although the difference did not reach statistical significance (p=0.1). At 4 years follow-up, the BUR-CPRE group had a larger bladder capacity (p=0.016). After BUR-CPRE, children had a lower rate of VUR, and when present, VUR was more often unilateral and lower grade compared to the CPRE alone group. Fewer numbers of children in the BUR-CPRE group depicted DMSA abnormalities. No children developed obstruction after BUR-CPRE and none have undergone repeat reimplantation. We documented a larger bladder capacity at the time of maximum follow-up available (4 years)-but further data are needed to confirm this observation. BUR-CPRE decreases the incidence and severity of VUR after CPRE, but the clinical significance of this remains unclear. We are encouraged by these initial results, but since BUR-CPRE does not uniformly eliminate VUR, we continue to proceed carefully in the well selected patient.

Bilateral ureteral endometriosis—an indolent, aggressive, and dangerous condition

To describe an unusual bilateral ureteral reimplantation due to endometriosis and to provide a flowchart of conservative decision making. Video description of a case, demonstrating a step-by-step explanation of the decision planning and description of the surgical steps in a female patient with bilateral ureteral endometriosis who had previously undergone operation for bowel endometriosis, and who presented with extensive disease in the posterior compartment with no symptoms besides bilateral renal function disruption. The study was reviewed and approved by the Hospital Beneficência Portuguesa de São Paulo Institutional Review Board. Tertiary referral center. Deep infiltrating endometriosis involving the ureter has an incidence of 0.1% to 1%, normally affecting the lower one-third of its segment, up to 4 cm above the vesicoureteric junction. Bilateral ureteral involvement occurs in 9% of cases. The absence of specific symptoms makes the diagnosis of this condition challenging. Lumbar pain develops when its involvement is complicated by marked obstruction with impaired renal function. Decompressive surgery is mandatory. The necessity of ureteroneocystostomy increases along with the severity of hydronephrosis, accounting for 62% of ureteral decompressive procedures. However, bilateral ureteroneocystostomy is a rare procedure, not exceeding 6% of ureteral reimplantations. This case illustrates a situation in which a patient with a previous bowel segmental resection presented with an advanced bilateral posterior deep infiltrating endometriosis, compromising the lower rectum below the previous anastomosis, vagina, posterior, and lateral parametrium bilaterally and both inferior hypogastric plexi. Hormonal therapy improved endometriosis symptoms but did not control the urinary tract involvement. Along with the patient, considering a high probability of intestinal, urinary, and sexual impairment, a conservative approach was chosen. The procedure started with adesiolysis, accessing the retroperitoneum and identifying both dilated ureters (Figs. 1 and 2). They were dissected as caudally as possible, until endometriosis fibrosis was reached, to have a bigger length of proximal ureter to allow a tension-free ureteroneocystostomy. The Retzius space was developed, and the bladder was freed and mobilized (Fig.3). After cutting the ureter, the proximal end was spatulated. The bladder dome was approximated to the psoas muscle with an interrupted suture to permit a tension-free ureteroneocystostomy. The detrusor muscle was opened for approximately 2 to 3 cm, exposing the vesical mucosa, which was subsequently opened. The posterior ureterovesical anastomosis was performed with running monofilament absorbable 4-0 sutures. A double-J stent was placed, and the anterior ureterovesical anastomosis was completed. The detrusor muscle was loosely closed over the ureter with interrupted absorbable sutures to avoid urinary reflux. A Maryland clamp was used to ensure sufficient entry of the tunnel. All these steps were repeated in the contralateral side. Successful performance of a bilateral laparoscopy tension-free ureteroneocystostomy with bilateral psoas hitch. The postoperative course was uneventful. Renal function was restored. One year after surgery, the patient remained asymptomatic, and endometriotic lesions showed no increase, thus remaining stable. Ureteral endometriosis can be aggressive and indolent. Decompressive procedures must be performed. The decision-making process must take into consideration the patient's characteristics and expectations. In selected cases, a conservative approach may be required, when future possible functional disfunctions can be worse than the actual symptoms. In those situations, close surveillance is necessary.

Robotic Management of Pelvic Lipomatosis—Experience with Difficulties Encountered and the Techniques to Successful Outcomes

BackgroundPelvic lipomatosis (PL) is a rare condition characterized by diffuse pelvic overgrowth of nonmalignant but infiltrative adipose tissue in perivesical and perirectal space. ObjectiveTo share our robotic experience and difficulties encountered and suggested techniques to overcome them successfully. It is the first series from India. Design, setting, and participantsA prospective observational study was conducted. All consecutive patients diagnosed with PL between 2016 and 2019 underwent robotic-assisted wide bladder fat extirpation and bilateral ureteral reimplantation (extravesical refluxing type) with double J stenting and were evaluated prospectively. Outcome measurements and statistical analysisDemographics, serum creatinine level, radiographic features, postoperative complications, and patient-reported outcomes were evaluated. Continuous variables are presented as median and range, as the sample size is very small. Results and limitationsWe encountered a total of five patients with PL. The median console time was 126 (range 120–130) min, with a median estimated blood loss of 120 (range 100–150) ml. Postoperative complications were Clavien-Dindo grade I in three cases, and the median hospital stay was 2 d. Distal ureteric margins showed subepithelial edema with submucosal fibrosis, and bladder fat biopsies were reported as adipose tissue with hemorrhage. At initial 3-mo and annual follow-ups, all patients had normal serum creatinine and there was no evidence of disease recurrence. Limitations of our study are the very small sample size (a low incidence of PL) and short follow-up time period (the question of how long the surgical effect will be sustained due to abnormal proliferation of fat cells remains unanswered). ConclusionsRobotic management of wide bladder fat extirpation and bilateral ureteral reimplantation with double J stenting has a good success rate and good outcome in PL. Patient summaryPelvic lipomatosis is a very rare condition. Robotic management in treating the condition has good outcome for the patient. Here, we have discussed the difficulties encountered in treating the condition and the techniques used to overcome them.

Intravesical and extravesical ureteral reimplantation in children with bilateral refluxing megaureter: comparison of results

Introduction. Extravesical ureteral reimplantation is an accepted technique for the surgical treatment of high-grade vesicoureteral reflux. However, many surgeons continue to use an intravesical technique, including for the megaureter. We present our experience and outcomes with these techniques for primary bilateral refluxing megaureter.Purpose of the study. To improve the results of surgical treatment of refluxing megaureter in children.Materials and methods. A retrospective study was performed of 95 patients who underwent ureteral reimplantation between 2006 and 2019. The age of patients at the time of surgery was from 4 months to 13 years (median — 27.6 months), boys were 71 (74.7%), girls were 24 (25.3%). All patients are divided into 2 groups depending on the method of treatment. Group 1 consisted of 65 patients who underwent Cohen single-stage bilateral transvesical ureteral reimplantation. Group 2 included 30 children who underwent two-stage Barry extravesical ureteral reimplantation. The interval between operations was from 1 to 63 months (median — 5.2 months). Patient demographics, surgical technique and outcomes were recorded. A successful postoperative outcome was defined as improved hydronephrosis and no vesicoureteral reflux.Results. Median follow-up period was 3.2 years. The overall success rate was 80% for patients and 88% for ureters. Postoperative grade III – IV reflux had 15 patients (15,8%) and 16 ureters (8,4%). Persistent ureterohydronephrosis had 4 children (4,2%) and 6 ureters (3,2%). The effectiveness of treatment for patients in the Cohen group was 77%, in the Barry group — 87% (p = 0.408), for ureters — 86% and 93%, respectively (p = 0.223). The difference was not significant despite the higher effectiveness extravesical technique.Conclusion. Extravesical and transvesical ureteral reimplantation are effective methods of treatment for bilateral refluxing megaureter in children.

Is Urinary Retention Following Extravesical Ureteral Reimplantation Still a Concern?

Transient urinary retention is a known complication of bilateral extravesical ureteral reimplantations. Recent studies have shown that the robotic-assisted bilateral extravesical reimplantation may have lower transient urinary retention rates than previously reported for the open approach. The purpose of this review is to compare urinary retention incidence in patients undergoing open versus robotic-assisted extravesical reimplantations. In some of the larger series, open bilateral extravesical ureteral reimplantation was noted to have a temporary urinary retention rate of 4–15%. In our recent experience with the open approach, we have noted a 2% incidence of transient urinary retention. In recent series of robotic-assisted bilateral extravesical reimplantations, transient retention was seen in 0–22%, with larger series favoring lower urinary retention rates. The incidence of transient urinary retention following open or robotic-assisted approaches in recent series is 0–2%, which is almost negligible. Dysfunctional elimination syndrome symptoms and constipation need to be aggressively treated preoperatively. Families of patients who undergo bilateral extravesical ureteral reimplantations, regardless of whether it is performed via the open or robotic-assisted approach, should not only be counseled of the small risk of transient urinary retention but should also be told that this can also be seen with any other surgical approach for the repair of primary vesicoureteral reflux.

Bilateral single system vaginal ectopic ureters: A rare variant

Bilateral single-system vaginal ectopic ureter (BSSVEU) is a very rare entity in pediatric urology. A 1-year-old girl was brought to outpatient clinic with continuous dribbling without normal voiding. The patient was diagnosed as BSSVEU by clinical findings, CT intravenous urography, genitoscopy and cystoscopy. Bilateral ureteric reimplantation was performed. Postoperative dry time was 2-3 hours after 3 months of follow-up and renal function was preserved at 3 months. Here, we report such a case and briefly discuss its diagnosis and management.

2133 Bilateral Ureteral Endometriosis - an Indolent, Aggressive and Dangerous Condition

Video Objective Describe an unusual bilateral ureteral reimplantation due to endometriosis and a flowchart of a conservative decision making. Setting Deep infiltrating endometriosis (DIE) involving the ureter has an incidence of 0.1 – 1%, normally affecting the lower third of its segment, up to 4 cm above the vesicoureteric junction. Bilateral ureteral involvement happens in 9% of the cases. The absence of specific symptoms makes its diagnostic challenging. Lumbar pain takes place when its involvement is complicated by a marked obstruction, with an impaired renal function. Decompressive surgery is mandatory. The necessity of ureteroneocystostomy increases along with the severity of hydronephrosis, accounting for 62% of the ureteral decompressive procedures. Even though, bilateral ureteroneocystostomy is a rare procedure, not trespassing 6% of ureteral reimplantations. Interventions This case illustrates a situation where a patient with a history of a bowel segmental resection presents with an advanced bilateral posterior DIE, compromising lower rectum below the previous anastomosis, vagina, parametrium (posterior and lateral) bilaterally and both inferior hypogastric plexus. Hormonal therapy improved endometriosis symptoms, but did not control the urinary tract involvement. Along with the patient, considering a probability of intestinal, urinary and sexual impairment, a conservative approach was decided and a laparoscopy bilateral ureteroneocystostomy was performed with a post-operative close clinical and imaging surveillance. Conclusion Ureteral endometriosis can be aggressive and indolent. Decompressive procedures must be performed. The decision making process must take in consideration patient's characteristics and expectations.

Ultrasound-guided quadratus lumborum block compared to caudal ropivacaine/morphine in children undergoing surgery for vesicoureteric reflex.

Ultrasound-guided quadratus lumborum block is a regional anesthetic technique which can provide perioperative analgesia for all age groups, including pediatric patients undergoing abdominal surgery. We hypothesized that the quadratus lumborum block would be as efficacious as a caudal block, the gold standard of pediatric lower abdominal regional anesthesia, in providing pain control after ureteral reimplantation but also have a longer duration. Forty-seven pediatric patients between the ages of 1 and 17years undergoing bilateral ureteral reimplantation surgery via a low transverse incision were enrolled and randomized into the quadratus lumborum block and caudal block groups. All blocks were performed preoperatively under general anesthesia. We analyzed the following outcomes: the requirement for narcotic analgesics, pain score, episodes of emesis, and complications at 0, 4, 24, and 48hours postoperatively. The study included 44 patients after excluding three who were ineligible. The fentanyl requirement for postoperative rescue analgesia during the first 24hours was significantly lower in the quadratus lumborum block group than in the caudal block group (median [interquartile range]: 0 [0-1] vs 3 [0-5], P=0.016, 95% confidence intervals: -4 to 0) but not at 30minutes, 4, or 48hours. No significant difference was observed in the pain scores or the incidence of interventions to treat nausea and vomiting during the entire period. No postoperative complication was observed. The quadratus lumborum block was more effective in reducing the postoperative opioid requirement for rescue analgesia during the initial 24hours than caudal ropivacaine/morphine.

Robot-assisted surgery for benign distal ureteral strictures: step-by-step technique using the SP® surgical system.

To describe the step-by-step techniques for robot-assisted ureteric reimplantation performed using the Vinci SP® surgical system (Intuitive Surgical, Sunnyvale, CA, USA), including different case scenarios with an educational purpose. Three consecutive patients diagnosed with distal benign ureteric strictures were counselled for ureteric reimplantation and consented to undergo surgery performed using the da Vinci SP surgical system. Demographics and peri-operative outcomes were collected after institutional review board approval (IRB 13-780). Patients provided informed consent having received an explanation for the adoption of the novel platform. The first patient was a woman referred to our institution for a left distal ureteric stricture after total hysterectomy for uterine fibroids with ureteric injury. The second patient was a man with BPH and recurrent UTIs, who was diagnosed with a 1.5-cm bladder stone and a large bladder diverticulum compressing the left distal ureter. The third patient was a man diagnosed with bilateral uretero-enteric anastomoses stricture status after radical cystectomy with orthotopic ileal neobladder urinary diversion for bladder cancer. The procedures were successfully completed. An extra port through a separate skin incision for the bedside assistant was placed for the first two procedures. In such cases, this additional port was used electively from the start of the procedure and did not represent a change in the treatment plan. Moreover, the port wound was used to accommodate the drainage. The bilateral ureteric reimplantation, however, was completed according to a pure single-site approach (no extra ports were placed out of the GelSeal cap). The mean operating times were 165, 150 and 180 min, respectively. Blood loss was 50 mL in all cases. No intra-operative complications occurred. Patients were discharged on postoperative days 1, 1 and 2, respectively, with normal serum creatinine levels. Neither transfusions nor major complications occurred. Robot-assisted reconstructive surgery for benign distal ureteric strictures is feasible and safe using the da Vinci SP surgical system.

Modified staged repair of bladder exstrophy: a strategy to prevent penile ischemia while maintaining advantage of the complete primary repair of bladder exstrophy

Penile ischemic injury is a reported catastrophic complication after complete primary repair of exstrophy (CPRE). Aiming to improve the bladder exstrophy-epispadias repair outcomes, the study institution adopted a modified staged exstrophy repair to incorporate the advantages of CPRE by avoiding concurrent epispadias repair and adding bilateral ureteral re-implantation and bladder neck tailoring (staged repair of bladder exstrophy with bilateral ureteral re-implantation [SRBE-BUR]) at the initial repair. It was hypothesized that such modifications minimize penile complications and prevent upper tract deterioration while enhancing bladder resistance and consequent capacity. Here, a comparative series of outcomes between CPRE and SRBE-BUR is reported. A retrospective cohort study including all exstrophy-epispadias male neonates managed in the study institution from January 2000 to December 2014 was performed. Patients were divided into those who underwent CPRE-BUR (group 1) and SRBE-BUR (group 2) (Figure). Baseline characteristics, peri-operative data, and long-term surgical outcomes were collected and analyzed for between-group comparison. Fisher exact and Mann-Whitney U tests were performed for statistical analysis. A total of 21 eligible patients were included: 10 in group 1 and 11 in group 2. Baseline characteristics were comparable. Two patients in group 1 had intra-operative penile ischemic injury (one with subsequent penile tissue loss), whereas none of the group 2 patients had intra-operative complications. No significant difference between the groups was noted for operative time; however, significantly lesser blood loss was noted in group 2. Comparable long-term surgical outcomes such as additional surgical intervention, urinary continence, bladder capacity, vesicoureteral reflux, hydronephrosis and recurrent urinary tract infections (UTIs) were noted. In addition, although subjective, better penile length and cosmesis were achieved by staging the repair (Figure). The SRBE with bilateral ureteral re-implantation is a safe alternative for the repair of the exstrophy-epispadias repair as it prevents the catastrophic complication of penile tissue loss, while having comparable long-term outcomes with the CPRE. Delaying epispadias repair avoids penile injury besides possible improvement of its overall cosmesis.

Unilateral open extravesical ureteral reimplanation with contralateral dextronomer/hyaluronic acid injection performed as an outpatient therapy

Historically, patients with unilateral high-grade vesicoureteral reflux (VUR) and contralateral low-grade or resolved VUR have been treated with bilateral intravesical ureteral reimplantation, which requires postoperative admission. If the high-grade VUR side is treated alone, then the contralateral side is at risk of developing recurrent or worsening VUR. Bilateral subureteric injection of dextronomer/hyaluronic acid (DHA) is another option that can be performed as an outpatient therapy, but a single injection is less effective for high-grade VUR. The safety and efficacy of an outpatient combination of open extravesical ureteral reimplantation (EVUR) and contralateral DHA injection were investigated. A retrospective review of children who had concomitant EVUR and subureteric injection of DHA between January 2005 and December 2015 was performed. Exclusion criteria were diagnosis other than VUR, repeat procedures, and patients with no follow-up. Patient characteristics, postsurgical complications, and follow-up imaging were evaluated. Febrile urinary tract infection (fUTI) was defined as ≥50,000Colony Forming Units (CFU) of an organism from clean-catch or catheterized urine and temperature ≥101.5F. Clinical success is defined as no fUTI for 1 year after the initial operation. Univariate analyses were used to identify risk factors for treatment failure. A total of 117 patients met inclusion criteria. Mean age at surgery was 6.0 years, and 85% were female. The mean pre-operative grade of VUR was 3.3 on the EVUR side and 0.6 on the contralateral side (42% resolved before treatment). Median follow-up was 12.2 months (interquartile range, 3.1-25.4). Sixteen patients (14%) had documented fUTI within 1 year, with a clinical success rate of 86%. Of these, five had a postoperative imaging showing resolution of VUR, increasing overall success to 91%. Postoperative fUTI was more common in patients with pre-operative bowel and bladder dysfunction (BBD) (P=0.003), but this was not associated with a higher reoperation rate (P=0.168). There were 11 total complications, with three grade 3 complications. This study is the first to report safety and outcomes of EVUR and contralateral DHA injection for patients with high-grade VUR with contralateral low-grade or resolved VUR. It was shown that it is an effective and safe treatment that can be performed as an outpatient therapy. Limitations to this study include the retrospective designand the clinical definition of success that is used in a cohort of patients from across the mountain west region without routine postoperative voiding cystourethrogram. Extravesical ureteral reimplantation and contralateral DHA injection can safely be performed as an outpatient therapy and are effective in the treatment of higher grade VUR with contralateral low-grade or resolved VUR. Treatment failure is more likely in patients with BBD.

Partial cystectomy and bilateral ureteroneocystostomy for resection of invasive transitional cell carcinoma involving the trigone area of the bladder in a dog - case report

ABSTRACT This study aims to report the technique of partial cystectomy and bilateral ureteral reimplantation for resection of transitional cell carcinoma (TCC) in the trigone region of the bladder and the long-term follow-up in a Bernesse Mountain dog. The proposed surgical technique was considered viable and a potential treatment option for TCC in bladder trigone, with benefits regarding the prevention of urinary tract obstruction due to neoplastic growth and local removal of the primary tumor, which may limit or delay the spread of the disease even without adjuvant chemotherapy. The main disadvantages related to the described technique are ureteral stricture, intermittent cystitis and local relapse. However, the results are acceptable considering the long-term survival of 610 days in the case described.