Cross-trigonal Ureteral Reimplantation Research Articles

Asymmetrical primary vesicoureteral reflux: Which is the best surgical strategy?

No report has been published regarding the recommended surgical treatment in patients presenting with symptomatic primary asymmetrical vesicoureteral reflux (VUR): high grade on one side and low grade on the contralateral side. The aim of this study was to evaluate the effectiveness and outcome of combined Lich-Gregoir extravesical reimplantation and subureteric Deflux® injection, of high grade and low grade VUR respectively. Non-inferiority to bilateral cross-trigonal reimplantation was investigated in terms of surgical complications, number of post-operative fUTIs and need for re-intervention. A monocentric retrospective study was undertaken of all consecutive children with primary asymmetrical VUR on MCUG treated over an 18-year period (2004-2022). Surgery was indicated following an episode of febrile urinary tract infection despite appropriate non-operative management. Demographic and clinical such as length of hospital stay for pain management, use of urinary Foley catheter and complications were analyzed. A total of 80 children met the study criteria: 40 patients underwent bilateral cross-trigonal re-implantation (Group 1) and 40 patients the combined Lich-Gregoir extra vesical reimplantation and Deflux® sub ureteric injection (Group 2). Complication and success rates were comparable in the two groups. The median hospital stay was significantly shorter for Group 2, with 50% of patients who were discharged on day 1. Moreover, the data showed a significant lesser need in number and length of bladder catheter and ureteral stents in Group 2. The technique proposed overcome the inconveniences of the other procedures that are commonly used in bilateral RVU: difficulty in retrograde catheterization or ureteroscopy after bilateral cross-trigonal reimplantation, the risk of transient bladder dysfunction after bilateral extravesical reimplantation and the low rate of success for high grade reflux of the sub ureteric Deflux® injection. The main limitation of the study lies in its retrospective nature and in the relatively short median follow-up. The combined Lich-Gregoir extra-vesical ureteral reimplantation and sub-ureteric Deflux® injection for the treatment of primary asymmetrical VUR is an effective alternative to the gold standard cross-trigonal ureteral reimplantation. Moreover, the position of the ureteric orifice is not modified in the eventuality of endourological procedures into adulthood.

Vesicoscopic Cross-Trigonal Ureteral Reimplantation for Vesicoureteral Reflux: Intermediate Results.

For the treatment of vesicoureteral reflux, the introduction of vesicoscopic procedures offers new perspectives for improving patient comfort and quality. Our aim was to examine whether minimally invasive vesicoscopic cross-trigonal ureteral reimplantation (VCUR) would meet expectations. Between 2012 and 2021, 99 girls and 35 boys with high-grade vesicoureteral reflux (VUR) underwent VCUR. For two boys, we failed to establish the pneumovesicum, leading to conversion to open surgery. The mean age was 4.5 years, ranging from 10 months to 18 years. VCUR was successfully performed in 132 patients, including 75 patients with bilateral VUR and 12 children with double ureters with unilateral or bilateral VUR, corresponding to a total of 229 operated ureters. The mean time of operation was 151 min for all patients. There were no perioperative complications, with the exception of three cases of pneumoperitoneum without consequences. Postoperatively, we recognized three cases of acute hydronephrosis, two of them required transient drainage. Three patients developed extravasation of urine after the postoperative removal of the transurethral catheter, rapidly resolved by new drainage. In two patients, we combined VCUR with laparoscopic heminephrectomy and opposite laparoscopic nephrectomy, respectively. Overall, mean postoperative hospital stay was 4.2 days. We observed recurrent VUR in seven ureters, resulting in a success rate for VCUR of 96.9%. These results demonstrate the feasibility of VCUR and its potential to displace open surgery with high safety and wide applicability.

Intraoperative Problems and Solutions in Pneumovesicum Laparoscopic Cross-trigonal Ureteral Reimplantation in Children by a Beginner Surgeon

Objective: Many beginner surgeons feel anxious when first doing the procedure. Some may encounter many intraoperative difficulties or problems, resulting in abandoning the technique. We will demonstrate our methods and the solutions to major intraoperative problems.Materials and Methods: A beginner surgeon performed the operation on 13 children with VUR (20 ureters) who met the indications for surgery between October 2016 and August 2017. Age ranged from 2 to 7 years. Each operation comprised 2 main steps: anchoring the urinary bladder wall to the anterior abdominal wall under cystoscopic vision, followed by a cross-trigonal ureteral reimplantation under pneumovesicum laparoscopy. The intraoperative problems, postoperative care, and follow-up periods were recorded to identify surgical outcomes.Results: Most significant, intraoperative problems were air leakage, bleeding, tear of the bladder mucosa above the tunnel, and inability to insert a tube into the ureter pre- and post-reimplantation. Most problems could be managed. Only one case had to be converted to open reimplantation due to uncontrolled air leakage. Postoperatively, 2 patients had hydroureteronephrosis at 4 weeks, but it eventually spontaneously regressed. One patient had cystitis, treated with oral antibiotics. Between the 1-year and 4-year follow-up, no patients had hydroureteronephrosis or urinary tract infections (UTI).Conclusion: Pneumovesicum laparoscopic ureteral reimplantation is a feasible technique for beginner surgeons. Although many intraoperative problems may be encountered, most can be managed, resulting in the completion of the laparoscopic procedure.

Pneumovesicoscopic Correction of Primary Vesicoureteral Reflux in Children: Our Initial Experience.

Purpose: The main objective of our prospective, descriptive, monocentric, longitudinal study is to demonstrate the feasibility of vesicoscopic cross-trigonal ureteral reimplantation under CO2 pneumovesicum in treatment on primary vesicoureteral reflux (VUR), analyze results, and specify the age limit of this approach. Materials and Methods: A total of 60 patients underwent transvesicoscopic ureteral reimplantation (33 boys, 27 girls) by the same surgeon from May 2011 to May 2015. All patients had primary VUR, and surgery was performed because of breakthrough urinary tract infection despite antibiotic prophylaxis and persistent high grade of VUR, especially in association with significant renal scarring, mean age at operation was 47.47 months (6 month-12 years). Of the 60 patients, 34 had bilateral reflux and 26 had unilateral reflux. The reflux grade in the total of 94 ureters was grade IV, V in 59.57%, grade III in 35.11%, and grade II in 5.32% in association with contralateral high-grade VUR. Results: The transvesicoscopic procedure was effectively completed in all patients without perioperative complication except one case of pneumoperitoneum that required exsufflation by open laparoscopy. The mean overall operative time decreased significantly with an average of 58.43 ± 11.26 minutes for unilateral reimplantation and 101.18 ± 26.5 minutes for bilateral reimplantation. The postoperative hospital stay was 3 days for all patients. The mean follow-up period was 3 years. Cystography was performed 3 months after surgery in all patients and showed the disappearance of VUR in 57/60 patients (95%) or 91/94 of ureters (97%). Persistent VUR was documented in 3 of 94 ureters and had resolved spontaneously at 12 months after reimplantation. Conclusion: Our preliminary results indicate that vesicoscopic ureteral reimplantation is safe and effective procedure with minimal morbidity when compared to traditional open method. It can be applied in children younger than 12 months.

Bilateral Robot-Assisted Laparoscopic Takedown Ureterostomy and Robot-Assisted Laparoscopic Dismembered Extravesical Cross-Trigonal Ureteral Reimplantation

Abstract Introduction: Unilateral robot-assisted laparoscopic dismembered extravesical cross-trigonal ureteral reimplantation (RADECUR) has demonstrated previously to be effective and safe in patie...

Minimally Invasive Dismembered Extravesical Cross-Trigonal Ureteral Reimplantation for Obstructed Megaureter: A Multi-Institutional Study Comparing Robotic and Laparoscopic Approaches

To compare 2 minimally invasive surgical options for the treatment of obstructed megaureter: robot assisted dismembered extravesical cross-trigonal ureteral reimplantation (RADECUR) and laparoscopic dismembered extravesical cross-trigonal ureteral reimplantation (LDECUR). A 2 arm retrospective comparative study, including all pediatric patients who underwent ureteral reimplantation of unilateral obstructed megaureter, either by RADECUR or LDECUR. Patient demographics, perioperative surgical data, complications, and results are described. The surgical technique in both arms was similar: dismembering of the ureter, performing an extravesical cross-trigonal detrusorotomy, and intracorporeal tailoring of the ureter when indicated, were the pivotal maneuvers utilized. The study included 95 patients (48 and 47 in the RADECUR and LDECUR arms, respectively) operated between the years 2016 and 2019. Overall, median age at surgery was 24 months (IQR 12-48) and median weight was 14 kg (IQR 11-21). Median operative time was 93 minutes (IQR 90-120) for RADECUR and 130 minutes (IQR 105-160) for LDECUR (P< 0.001). Intracorporeal excisional tapering was performed in 11 of the RADECUR patients and 19 LDECUR patients. Grade 1-2 Clavien-Dindo complications occurred in 7 patients, and grade 3 complication in 1 patient in the RADECUR arm. In the LDECUR arm, grade 1-2 complications occurred in 2 patients, and 2 had a grade 3 complications. Surgical success was achieved in 97% and 94% in the RADECUR and LDECUR groups, respectively. Unilateral robotic extravesical cross-trigonal ureteral re-implantation for treatment of obstructed megaureter in the pediatric population is safe and effective both for RADECUR and LDECUR. Operative time is significantly shorter for RADECUR.

A Novel Surgical Technique for Obstructed Megaureter: Robot-Assisted Laparoscopic Dismembered Extravesical Cross-Trigonal Ureteral Reimplantation—Short-Term Assessment

Purpose: To describe our experience with robot-assisted laparoscopic dismembered extravesical cross-trigonal ureteral reimplantation (RADECUR)-a novel minimally invasive surgical technique for treatment of obstructed megaureter. Materials and Methods: A retrospective review of our prospectively collected data, of all pediatric patients who underwent unilateral RADECUR for the treatment of primary or secondary obstructed megaureter at two medical centers during a 3-year period. Patient demographics, perioperative data, surgical technique, complications, and results are described. Results: Thirty-five pediatric patients underwent RADECUR between January 2016 and May 2019. Median age and weight at surgery were 28 months (interquartile range [IQR]: 20-58) and 20 kg (IQR: 13-27), respectively. There were no conversions to an open procedure. Median console time was 100 minutes (IQR: 90-125). Ten patients underwent intracorporeal excisional tapering of the obstructed ureter. Mean pre- and postoperative ureteral diameters were 14.5 mm (IQR: 12-18) and 7 mm (IQR: 0-10), respectively (p < 0.0001). All but one patient demonstrated a reduction in hydronephrosis and ureteral diameter on follow-up ultrasonography. Grade 1-2 Clavien-Dindo complications occurred in five patients (14%) and another patient developed a grade 3 complication. Three patients developed postoperative febrile urinary tract infection, one of them was found to have high-grade reflux and subsequently underwent open ureteral reimplantation. Conclusions: Unilateral robotic extravesical cross-trigonal ureteral reimplantation for treatment of obstructed megaureter in the pediatric population is safe and effective. Further larger scale comparative studies with other surgical techniques are needed to determine the role of RADECUR in the armamentarium of treatment for distal ureteral obstruction.

Outcome of salvage ureteral reimplantation after endoscopic treatment failure for high-grade vesicoureteral reflux compared to primary ureteral reimplantation.

Introduction:Surgical treatment of vesicoureteral reflux is required after conservative treatment has failed. However, there is a controversy if fibrosis related to previous attempts of dextranomer/hyaluronic acid (Dx/Ha) injection increases the risk of surgical difficulty and postoperative complications. Therefore, the purpose of our study was to compare the outcome of salvage ureteral reimplantation (SUR), after failed endoscopic therapy, to that of primary ureteral reimplantation in patients with high-grade primary vesicoureteral reflux (VUR).Materials and Methods:We conducted a retrospective analysis of children, <14 years old, treated for Grade IV or V VUR, between 1998 and 2014. Cases were classified into the SUR or the PUR group. Cases of secondary VUR were excluded. All patients were treated using a cross-trigonal ureteral reimplantation technique by two surgeons. The following demographic and clinical variables were included in the analysis: presentation, reflux severity, scarring on imaging, age at endoscopic injection, total amount of Dx/Ha injected, operative time, postoperative hospital stay, operative complications, incidence of febrile urinary tract infections (UTIs) after surgery, and persistent VUR. Between the groups, differences were evaluated using Fisher's exact test.Results:Twenty-six patients were included, 19 in the SUR and 7 in the primary ureteral reimplantation (PUR) group. In the SUR group, 12 cases had a bilateral VUR and 7 had a unilateral VUR, with 4 bilateral and 3 unilateral VUR cases in the PUR group. In the SUR group, 13 patients had received one Dx/Ha injections, with the other 6 receiving two injections, of 0.5 ml of Dx/Ha (range, 0.5–2.0 ml). A bilateral reimplantation was performed in 14/19 patients in the SUR group and 4/7 in the PUR group. The median age at surgery was 4 years in the SUR group and 3 years in the PUR group (P < 0.02). The median operative time was comparable between the groups (120 and 140 min for the SUR and PUR groups, respectively, P = 0.73), with a comparable length of hospital stay (5 and 6 days, respectively, P = 0.061). Blood loss was generally <10 ml, except in three cases in the SUR group, due to difficult dissection. Over the median follow-up of 1 year, persistent Grade III SUR was identified in only one patient in the SUR group, with no occurrence of febrile UTIs postoperatively.Conclusion:SUR for high-grade primary VUR after failed Dx/Ha injection has the same success rate as PUR, with no significant complication rate, although the necessary dissection may be more difficult.

Vesicoscopic cross-trigonal ureteral reimplantation: High success rate for elimination of primary reflux

Open ureteral reimplantation (UR) is the gold standard for the surgical management of vesicoureteral reflux (VUR). There have been increasing reports on robot-assisted UR, but this approach remains controversial due to reports suggesting increased complications and reduced success compared with open repair. This study presented extensive experience with vesicoscopic ureteral reimplantation (VR) for primary reflux. In this procedure, cross-trigonal reimplantation was performed in a manner analogous to open repair under carbon dioxide 'pneumovesicum'. To review outcomes of vesicoscopic cross-trigonal ureteral reimplantation and compare them with other minimally invasive approaches for the correction of reflux. All patients who underwent VR at the current institution were retrospectively reviewed. The following were recorded for each patient: age, sex, grade of reflux, operative time, outcome, and complications. The series consisted of 182 consecutive patients who underwent VR. There were 165 girls and 17 boys. Mean age was 7.03 years (range 16 months-38.2 years). Fifteen had failed prior injection therapy. Of the 182 patients, 135 underwent bilateral repairs and 47 unilateral. Mean operative time for bilateral repairs was 197 (112-284) minutes and 169 (99-288) for unilateral. Major complications included two ureteral obstructions: one resolved with stent placement and the other underwent re-operative reimplantation. Postoperative voiding cystourethrogram (VCUG) was obtained in 100 patients and was normal in 93 (93%). Four of these failures occurred in the first 30 patients. Of the last 49 patients tested, 48 were normal, suggesting a 98% effective success rate after the learning curve. Vesicoscopic ureteral reimplantation is an approach that completely recreates all aspects of open cross-trigonal repair. Complications were uncommon and success rates were very high in the current study. Vesicoscopic ureteral reimplantation is a minimally invasive procedure for the definitive repair of primary reflux. After the learning curve at the current institution, success rates were found to be equivalent to open repair and were higher than published reports of robot-assisted procedures.

A Simple and Novel Method to Attain Retrograde Ureteral Access after Previous Cohen Cross-Trigonal Ureteral Reimplantation

Objective: To describe a simple, novel method to achieve ureteric access in the Cohen crossed reimplanted ureter, which will allow retrograde working access via the conventional transurethral method. Materials and Methods: Under cystoscopic vision, suprapubic needle puncture was performed. The needle was directed (bevel facing) towards the desired ureteric orifice (UO). A guidewire (with a floppy-tip) was then inserted into the suprapubic needle passing into the bladder, and then easily passed into the crossed-reimplanted UO. The distal end of the guidewire was then removed through the urethra with cystoscopic grasping forceps. The straightened ureter then easily facilitated ureteroscopy access, retrograde pyelogram studies, and JJ stent insertion in a conventional transurethral method. Results: The UO and ureter were aligned in a more conventional orthotopic course, to allow for conventional transurethral working access. Conclusion: A novel method to access the Cohen crossed reimplanted ureter was described. All previously published methods of accessing the crossed ureter were critically appraised.

Evaluation of Mathisen's technique for ureteral reimplantation in children with primary vesicoureteral reflux

Although cross-trigonal ureteral reimplantation (Cohen) is a commonly used technique in children, it represents a non-physiological transfer of the ureteral orifices and may prove challenging with regard to endoscopic ureteral operations in later life. In 1964, Mathisen described an alternative method of ureteral reimplantation with lateralization of the neohiatus, creating an orthotopic course of the submucosal ureter. We have evaluated success and complication rates of both techniques that were applied sequentially at our departments. Forty-eight consecutive patients (83 ureters, 24 males/24 females) following Mathisen reimplantation were compared with 53 consecutive patients (98 ureters, 30 males/23 females) following Cohen reimplantation. Inclusion criteria were primary vesicoureteralreflux (VUR) and no previous intervention. Reflux grades (Mathisen 58 ureters/69.9% VUR ≥ III; Cohen 66 ureters/66.7% VUR ≥ III) and the occurence of other complicating factors (ureteroceles, megaureters, posterior urethral valves) in both groups were comparable. After Cohen's reimplantation there were no immediate complications requiring intervention; during follow-up (mean 28.2 months) three patients (5.6%) suffered febrile urinary tract infections (UTIs), of which one (1.8%) was diagnosed with a persisting VUR. Persistent hydronephroses (≥II SFU) were recorded in six patients (13.2%). After reimplantation using Mathisen's technique, two patients (4.1%) suffered significant intravesical bleeding; during follow-up (mean 23.06 months) four patients (8.3%) suffered febrile UTIs, and seven patients (14.5%) were diagnosed with persisting VUR after a mean follow-up of 10.8 months. The patients with persistent VUR had more commonly high-grade (IV and V) VUR initially, compared to the whole group. Two patients (4.1%) had persistent hydronephroses (≥II SFU). Mathisen's technique for ureteral reimplantation yielded a significantly (p=0.0256 patients, p=0.006 ureterorenal units) lower success rate (85.5% patients, 89.2% ureterorenal units) in comparison with Cohen's technique (98.2% patients, 99% ureterorenal units). Although there was no intervention for obstruction, persistent hydronephrosis was more common in the Cohen group (13.2% vs. 4.1%, n.s.). Despite the advantages of an orthotopic ureteral orifice close to the bladder neck, as achieved by Mathisen's reimplantation, cross-trigonal ureteral reimplantation proved more reliable for VUR correction. As regards optimizing the results, patient selection for either technique could prove essential. Nevertheless, as regards the difficulties with ectopic ureteral orifices in the Cohen technique in the long-term follow-up, the concept of anatomic, orthotopic ureteral reimplantation should be pursued and the technique should be further refined.

IJU this issue

This month's issue covers a wide range of topics, including one Review Article, seven Original Articles, two Urological Notes and two Letters to the Editor. The Review Article by Jinzaki et al. (Tokyo, Japan) deals with the role of computed tomography (CT) urography for imaging of upper tract urothelial carcinoma. For some time, CT urography has replaced intravenous urography for first-line imaging of patients with a risk of upper tract urothelial carcinoma. However, CT urography has a number of limitations. This Review Article summarizes the present status, issues and future perspective of CT urography in clinical practice, and will be informative for readers. The Original Article by Schmid et al. (Boston, USA) reports a previously little-known adverse effect of gonadotropin-releasing hormone (GnRH) agonists. The authors analyzed a cohort of 52 905 patients with localized prostate cancer included in the SEER database, and found that increased administration of GnRH agonists was associated with a higher risk of community-acquired respiratory tract infections. The relationship between androgen deprivation therapy and respiratory infections had drawn attention since the first report by Chung et al. from Taiwan (PLoS ONE 2014). Contrary to that report, however, Schmid et al. detected no relationship between bilateral orchiectomy (surgical androgen deprivation therapy) and respiratory events. Whether or not GnRH agonists really increase the risk of respiratory infection, and whether there is a case for surgical androgen deprivation therapy and GnRH antagonists is an interesting issue. The Original Article by Iremashvili et al. (Miami, USA) provides somewhat intriguing and thought-provoking information on active surveillance (AS) of prostate cancer. The authors showed that pre- and post-diagnostic prostate-specific antigen kinetic parameters, such as prostate-specific antigen velocity and doubling time, did not add predictive value in terms of disease progression during AS. Prostate-specific antigen kinetics have been considered a predictor of disease progression during AS, and are still widely used by many urologists, as stated in the Editorial Comment. So what should we use as a reliable predictor of disease progression during AS? Tips and hints can be found in the text and Editorial Comment. The Original Article by Naitoh et al. (Kyoto, Japan) introduces the surgical procedure of transvesical laparoscopic cross-trigonal ureteral reimplantation for double renal pelvis and ureter with or without ureterocele. Transvesical laparoscopic cross-trigonal ureteral reimplantation itself was reported over 10 years ago, and the authors are the first to have applied it to double renal pelvis and ureter along with bladder reconstruction for ureterocele. Although this procedure might be somewhat challenging, the surgical technique is described in detail. Laparoscopic surgeons are encouraged to consider this minimally-invasive surgical procedure. The Urological Note by Krabbe and Lotan (Dallas, USA) provides convincing information. The authors found that the overall risk of lung cancer in bladder cancer patients who participated in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial and National Lung Cancer Screening Trial was 4.1–5.0%, being higher than the overall incidence of lung cancer in the National Lung Cancer Screening Trial (3.9%), and far exceeding rates in the general population. Therefore, they suggest that patients newly diagnosed with bladder cancer should be screened for lung cancer using low-dose CT of the chest, although the current bladder cancer guidelines do not make recommendations regarding screening for other cancers. Considering that bladder cancer and lung cancer have the same risk factors, including smoking and arsenic in drinking water, and lung cancer is the most common cause of death from cancer, as stated in the Editorial Comment, the authors might be right. None declared.

V8-10 AN EFFICIENT TECHNIQUE TO ENGAGE AND CATHETERIZE A URETERAL ORIFICE IN DIFFICULT SITUATIONS

You have accessJournal of UrologyBladder Oncology/Testis/Transplantation/Trauma1 Apr 2016V8-10 AN EFFICIENT TECHNIQUE TO ENGAGE AND CATHETERIZE A URETERAL ORIFICE IN DIFFICULT SITUATIONS Cu Phan, Stephanie Y. Johng, Stephanie G. Wong, Alan Hung, and Dominic D. Tran-Nguyen Cu PhanCu Phan More articles by this author , Stephanie Y. JohngStephanie Y. Johng More articles by this author , Stephanie G. WongStephanie G. Wong More articles by this author , Alan HungAlan Hung More articles by this author , and Dominic D. Tran-NguyenDominic D. Tran-Nguyen More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.753AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Catheterization of the ureteral orifice can be very challenging. These situations include patients with a very large median lobe of the prostate, a transplanted kidney, a cross-trigonal ureteral reimplantation, tumors/ stones obstructing the lumen of the ureteral orifice, and a distal ureteral stricture. We will present a technique that makes ureteral catheterization efficient and easier to perform. METHODS Use a 5 Fr. Open-ended ureteral catheter and an angled tip glidewire (hydrophilic guidewire with an angled tip). Insert the open-ended catheter into the scope and insert the glidewire sticking out of the inserted end. We can adjust the length, and thus curvature, of the glidewire sticking out of the inserted end. Use the Kelly clamp or mosquito clamp at the distal end of the catheter to fix the catheter to the glidewire inside. In order to steer the angled tip inside the bladder, we just need to gently rotate the clamp from the outside. The angled tip glidewire inside the bladder is soft and flexible. It can get into a challenging ureteral orifice easier than a regular open-ended catheter. We then advance both the catheter and the glidewire up the ureter. The catheter is fixed to the glidewire by the clamp. RESULTS We have used this technique to catheterize multiple patients with a transplanted kidney, cross-trigonal ureteral implantation, and with very large prostates. Once the catheter gets inside the ureteral orifice and into the ureter, we can easily release the clamp to advance the glidewire® quickly. CONCLUSIONS This technique is simple and more effective than traditional techniques – for example, using an Alberran deflecting bridge or an angled tip angiographic catheter. The Alberran deflecting bridge may also catch organs such as the prostate and cause bleeding. On the other hand, the angled tip angiographic catheter, although also curved, is static – meaning the surgeon has no flexibility in adjusting the curvature of the catheter. The advantage of using a glidewire® as opposed to simply using an open-ended catheter is that the curvature can easily be manipulated and that the wire is flexible enough to fit into tortuous paths such as a J-hook ureter. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e774 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Cu Phan More articles by this author Stephanie Y. Johng More articles by this author Stephanie G. Wong More articles by this author Alan Hung More articles by this author Dominic D. Tran-Nguyen More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Neurologic complications of percutaneus nephrolithotomy.

Neurologic complications of percutaneus nephrolithotomy.

Salvage Endoscopic Correction of High-Grade Vesicoureteral Reflux After Unsuccessful Cross-Trigonal Ureteral Reimplantation

Introduction: Persistent vesicoureteral reflux (VUR) after reimplantation of ureters requiring reoperation has been reported in up to 7.5% of cases. This video demonstrated a successful endoscopic salvage option for correction of persistent, high-grade VUR after a bilateral cross-trigonal ureteral reimplantation. Methods: A 19-month-old female with a double collecting system and a ureterocele underwent a Cohen cross-trigonal ureteral common sheath reimplantation. A year later, she presented with persisting right-sided grade 5 VUR. We corrected her reflux with salvage endoscopic injection of dextranomer/hyaluronic Acid (Dx/HA). Results: The major challenge in this case was the ureteral orifice axis post-Cohen cross-trigonal ureteral reimplantation, which was nearly perpendicular to the axis of the urethra-cystoscope axis. We used a 4F whistle-tip catheter, which was inserted into the right ureter. The rigidity of this catheter allowed us to torque the ureter to reduce the angulation and allowed the cystoscope to be inserted into the dilated refluxing ureter. Four injections of Dx/HA were performed in the intramural part of the ureter and one at the ureteral orifice location. A final injection was placed below the ureteral tunnel just proximal to the orifice. A voiding cystourethrogram three months postimplantation confirmed the resolution of the reflux. Conclusion: This video demonstrated a successful endoscopic salvage option for correction of persistent, high-grade VUR after a bilateral cross-trigonal ureteral reimplantation. We recommend using a ureteric catheter to align the reimplanted ureter with the urethra-cystoscope axis, followed by insertion of the cystoscope into the ureter for the first intramural injection of Dx/HA. No competing financial interests exist. Runtime of video: 7 mins 54 secs

Transvesicoscopic Ureteral Reimplantation in Children with Bilateral Vesicoureteral Reflux: Surgical Technique and Results

To report our initial experience with transvesicoscopic cross-trigonal ureteral reimplantation (TVUR), describing stepwise the surgical procedure and determining critical aspects of this surgery in the actual surgical field. Between September 2008 and April 2010, 48 patients with bilateral vesicoureteral reflux (VUR) underwent TVUR. To identify the critical aspects affecting the surgical difficulty, we divided our TVUR procedure into four steps: TVUR set-up, mobilization of ureters, creation of submucosal tunnels, and ureterovesical anastomosis. To evaluate the evolution of our TVUR, we analyzed changes in the operative time and complications versus increase in surgeon experience (dividing our cases into three groups: the first third, the second third, and the last third). Changes in operative time for all four steps of TVUR were analyzed separately, as well as change in overall operative time. Of a total of 48 cases, 45 patients underwent TVUR successfully except for 3 cases of open conversion. Among the 45 cases, the mean overall operative time was 155.6 min. In 1 patient, proximal migration of the ureteral catheter occurred. No other perioperative complications were observed. The mean postoperative hospital stay was 1.6 days. The VUR resolution rate was 96.4%. Upon analysis of our results by step, Step 4 (ureterovesical anastomosis) required the largest portion of the overall operative time in most cases. During the early period of our TVUR, we encountered several technical difficulties. However, the operative times for all four steps were stabilized with increasing number of cases, without deteriorating surgical outcomes. Our report demonstrates that TVUR might potentially be a safe and effective alternative to open ureteral reimplantation in children with VUR, with a shorter learning curve than expected.

A New Technique for Retrograde Flexible Ureteroscopy after Cohen Cross-Trigonal Ureteral Reimplantation

Purpose: Retrograde ureteral access after cross-trigonal ureteral reimplantation can be challenging. We present our experience with retrograde ureteral catheterization and flexible ureteroscopy after Cohen cross-trigonal reimplantation in patients presenting with ureteral stones. Materials and Methods: Cystoscopy is performed and a Tiemann ureteral catheter is inserted into the involved ureteral orifice. A retrograde ureterography is performed and hydrophilic guide wire is passed up to the kidney. A dual-lumen ureteral access sheath is then passed under x-ray control underneath the ureteral stone. The flexible ureterorenoscope is passed under x-ray control up to the stone which is then fragmented with a holmium laser. Results: From June 2006 to June 2010, this technique was successful in 8 patients without acute or delayed sequelae. Conclusions: Where the endourological expertise is readily available, the ureter can be accessed retrogradely even after Cohen cross-trigonal ureteral reimplantation in a safe, straightforward and effective modality.

Pediatric Robotic Extravesical Ureteral Reimplantation: Comparison With Open Surgery

Robotic assisted laparoscopic extravesical ureteral reimplantation is becoming more widely used as an alternative to open reimplantation. To date, no direct comparison to the open approach in a similar cohort exists. We review a single surgeon experience and compare the outcomes of robotic assisted laparoscopic extravesical ureteral reimplantation and open ureteral reimplantation in children with vesicoureteral reflux. We retrospectively reviewed the charts of 25 pediatric patients (mean age 69 months, range 3 to 144) who underwent robotic assisted laparoscopic extravesical ureteral reimplantation for unilateral or bilateral vesicoureteral reflux between February 2006 and December 2009. A total of 25 patients undergoing open cross-trigonal ureteral reimplantation (mean age 50 months, range 8 to 110) during the same period were used for comparison. All cases were performed by a single surgeon. There were no conversions or intraoperative complications. There was no correlation between age or weight and operative time, length of stay or total analgesia used. Mean operative time was 12% longer in the robotic group vs controls (p <0.05). Mean length of stay (33 vs 53 hours) and pain medication usage were significantly less in the robotic group (p <0.001). Time to first oral intake was not significantly different. There were 3 episodes of transient urinary retention in the robotic group, all in patients undergoing bilateral reimplantation. The overall success rate, defined as no radiographic or clinical evidence of residual reflux, was 97% for robotic assisted laparoscopy after a mean followup of 16 months, compared to 100% for open reimplantation. Robotic assisted laparoscopic extravesical ureteral reimplantation appears to be a safe and efficacious option for repair of vesicoureteral reflux. This early series shows success rates similar to the open approach. We observed decreased length of stay and use of postoperative narcotics. These findings may serve to justify further exploration of this technology and to provide data for design of a prospective trial, although the relative value of specific reductions in morbidity will need to be defined.

Ureteral Stents Do Not Cause Bacterial Infections in Children After Ureteral Reimplantation

To determine, in a prospective study, the incidence of bacterial colonization and the risk of bacterial infection of indwelling double-J stents in children undergoing ureteral reimplantation. In a balance between the safety and comfort of the child, the need for postoperative stenting of the reimplanted ureters has been discussed. It is unknown whether an indwelling double-J stent after ureteral reimplantation would be a risk factor for postoperative urinary tract infection. From 2005 to 2010, 209 children (138 girls and 71 boys; median age 3.8 years) with vesicoureteral reflux underwent unilateral or bilateral cross-trigonal ureteral reimplantation (352 ureters). All children received a single dose of gentamicin (2 mg/kg body weight) and a preoperative bladder rinse with 10% polividone-saline solution. A transurethral catheter was also left postoperatively for 2 (unilateral) or 3 (bilateral) days. The ureter was stented with a 8-22 cm multilength catheter. At 3 weeks postoperatively, the ureteral catheters were removed and investigated for bacterial colonization. Of the 209 children, 10 (4.8%) developed a urinary tract infection within the first 6 weeks after ureteral reimplantation. Of the remaining 199 children without any symptoms, 13 (6.5%) had a positive urine culture at removal of the catheters. Of the 199 children without any symptoms, 90 (45.2%) had a positive culture of one or more segments of the double-J catheter. Although the colonization rate of ureteral stents in our study was 42.9%, the rate of urinary tract infection during the first 6 weeks after ureteral reimplantation using indwelling ureteral stents was only 4.6%. We have concluded that the clinical significance of bacterial colonization of an indwelling ureteral stent is low, and therefore, ureteral stents can be used safely.

Pneumovesicoscopic Correction of Primary Vesicoureteral Reflux (VUR) in Children. Our Experience

We report our experience with pneumovesicoscopic cross-trigonal ureteral reimplantation to correct primary vesicoureteral reflux (VUR) in children. 14 children (10 girls, 4 boys, aged 4 to 12 years) with persistent VUR ≥ grade III (5 bilateral, 19 refluxing ureters) underwent pneumovesicoscopic Cohen's cross-trigonal reimplantation. Under cystoscopic control, a first midline 5-mm trocar was introduced for a 0°\30° telescope at the dome of the bladder, and 2 left and right 3- or 5-mm trocars were inserted through the anterolateral wall. The ureter was freed by creating a sharp plane between the detrusor muscle and the ureteral wall. If necessary, the ureter was tailored outside the bladder. Submucosal tunnel(s) were prepared with the help of scissors and graspers. The detrusor at the site of the ureter mobilization was repaired and ureteroneocystomy was performed using 4-5 interrupted absorbable sutures. A 12-Ch Foley catheter was introduced at the site of the dome port. The urethral and suprapubic catheters were removed 2-3 days after the procedure and the patients were discharged on day 3. One boy developed mild suprapubic emphysema postoperatively. Mean operating time was 136 min (range 80-230 min). No patient required conversion to the open technique. Renal US, VCUG, and MAG3 radionuclide scans were obtained in all patients between 3-6 months postoperatively, and provided evidence of reflux resolution in 13 out of 14 patients. Our experience seems to confirm that pneumovesicoscopic cross-trigonal ureteral reimplantation can be performed safely and effectively.