Extravesical Ureteral Reimplantation Research Articles

Primary repair vs Delayed staged repair in infants with primary obstructive megaureters and their long term outcomes – A single centre experience

There is paucity of literature in the management of infants with primary obstructive megaureters undergoing upfront primary repair with an extravesical technique of ureteral re implantation (with or without ureteral tailoring). To compare 2 different approaches in the management of infants with unilateral primary obstructive megaureters. This was a retrospective analysis of a prospectively maintained data base between 2005 and 2021. Infants <1 year with unilateral primary obstructive megaureter were included. They were divided into 2 groups: those who underwent an upfront extravesical ureteric reimplantation with or without ureteral tailoring during infancy -Primary Repair (PR), and those who initially underwent a low end cutaneous ureterostomy during infancy followed by take down of ureterostomy and intravesical ureteric reimplantation after 1 year of age -Delayed staged repair (DSR). Children presenting with sepsis, in whom a diversion was imperative, were excluded. All children were followed up annually after their definitive repair with a renal ultrasound, diuretic renogram, estimated glomerular filtration rate and assessment of voiding dysfunction if present. The 1st year and 3rd year follow up details were collated and analysed. Failure was defined as persistent obstructive pattern on renogram with worsening differential renal function or presence of high grade reflux with recurrent breakthrough urinary tract infection; both of which necessitated a redo reimplantation following the definitive surgery. There were 18 infants in Primary repair and 16 infants in Delayed Staged Repair. Urinary tract infections was the commonest presenting symptom amongst both groups i.e. > 50%.The post operative complication rate was 11% in Primary repair and 31% in Delayed Staged Repair. One child in each of the groups (2 girls) required redo reimplantation (5.8%). At the end of the 3rd year follow up (from the definitive repair) there was significant reduction in the hydronephrosis, improvement in the differential renal function with no evidence of obstruction and improvement in the estimated glomerular filtration rate amongst all in both groups which was statistically significant i.e. p<0.05. The success rate was 94.4% in Primary Repair and 93.75% in Delayed Staged Repair. The mean follow up was 9.7 years amongst those undergone Primary Repair and 9 years amongst those undergone Delayed Staged Repair. Primary extravesical ureteral reimplantation may be considered as the preferred line of management of unilateral obstructed megaureters during infancy.

Robotic approach to the uretero-vesical junction in children: An international multicentric retrospective study.

Robot-assisted approach to UVJ is getting more and more used in pediatric patients. In this retrospective study 26 patients affected by nephro-urological malformations, robotic-surgically treated from 2016 and 2021 at 3 Pediatric Surgery Department were included: 3 (11.5%) primary obstructive megaureter, 2 (7.7%) dysplastic kidneys, 3 (11.5%) duplex collecting system, 18 (69.2%) primary vescico-ureteral reflux (VUR). Mean age at surgery was 6 years old. 22 (84.6%) underwent Lich Gregoire extravesical ureteral reimplantation, 4 (15.4%) total nephroureterectomy. Mean operative time was 230 min. No conversions or intraoperative complications. Median hospital stay was 4 days. There were 4 (15.38%) postoperative complications: 3 (11.54%) persistent VUR and 1 (3.84%) refluxing megaureter. 2 (7.7%) redo-surgery. Robotic Surgery should be considered a safe and effective technique for treatment of UVJ anomalies in children, because it firstly allows surgeons to approach both upper and lower ureteral ends without modifying trocars' placement.

Laparoscopic extravesical ureteric reimplantation for high grade vesico-ureteric reflux in pediatric population: Our experience

Laparoscopic extravesical ureteric reimplantation for high grade vesico-ureteric reflux in pediatric population: Our experience

Laparoscopic robotic takedown ureterostomy with extravesical cross-trigonal reimplantation after end cutaneous ureterostomy

Introduction The main goal of managing an obstructed megaureter (OMU) is to preserve the function of the affected kidney. To preserve the upper urinary tract, end cutaneous ureterostomy (ECU) seems to be a promising temporizing option. We aimed to evaluate our experience with ECU in patients with primary and secondary OMU and to demonstrate an efficacy of robot-assisted laparoscopic takedown ureterostomy and subsequent extravesical ureteric reimplantation. Materials and methods Retrospective analysis of patients that underwent ECU due to primary or secondary megaureter between 2003 and 2020. Nineteen patients (12 males, 7 females) with a mean age of 4.2 ± 3.5 months (mean ± standard deviation) underwent ECU of 27 renal units. Of those, 11 (57.9%) had primary OMU and 8 (42.1%) had secondary OMU. Undiversion was performed in 16 (84%) out of 19 patients (20 renal units out of 27 [74%]). Results In the vast majority of the cases, we have observed improvement in the hydronephrosis and renal function after ureterostomy. After reimplantation ultrasonography showed either stable or further improvement in hydronephrosis in 80% of patients. Robot-assisted laparoscopic patients had shorter admission period and indwelling catheter time after the surgery. Conclusions End cutaneous ureterostomy is a safe and effective temporary procedure for the treatment of progressive primary and secondary megaureters. Robot-assisted laparoscopic takedown of ureterostomy with subsequent reimplantation seems to be a good alternative for undiversion and subsequent reimplantation in these patients.

Robotic ureteral reimplantation and uretero-ureterostomy treating the ureterovesical junction pathologies in children: technical considerations and preliminary results.

Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR) and robotic ureteroureterostomy (RUU) are two mini-invasive surgical techniques that have begun to be performed in pediatric urology in recent years. RALUR has been employed especially for VUR treatment, while RUU is considered principally in case of complex doubled ureteral systems. Our aim is to discuss the safety and feasibility of these approaches in children, focusing on technical considerations and supporting their use in different anomalies and pathologies of the ureterovesical junction. We retrospectively collected data about 58 patients who underwent 44 dismembered RALUR (D-RALUR), 28 non-dismembered RALUR (ND-RALUR) and 5 RUU between May 2020 and December 2021. Indications for surgery were primary or secondary vesicoureteral reflux, megaureter, secondary UVJ obstructions, complicated doubled ureteral systems. Mean age was 3.5years (range 0.6-12.9) and mean weight 17.1 (range 7.2-80). No intraoperative complications occurred nor conversion to open approach were reported. Major postoperative complications were reported in 11.7% of cases with a higher incidence for ND-RALUR. Mean hospital stay was 2.14days (range 1-8). Success rate at the short-term follow-up was 91.9% for D-RALUR, 96.3% for ND-RALUR and 100% for RUU. RALUR and RUU are two feasible and safe procedures to perform in children. RALUR represents the most required and adequate technique in the treatment of UVJ pathologies, however, in selected cases RUU could represent an effective alternative that has to be considered.

Pediatric robot-assisted extravesical ureteral reimplantation (revur) in simple and complex ureter anatomy: Report of a multicenter experience

Robot-assisted extravesical ureteral reimplantation (REVUR) is a well established approach for surgical treatment of pediatric vesicoureteral reflux (VUR). However, further evidence is needed to confirm its efficacy even in case of complex anatomy. This study aimed to further confirm the evidence that REVUR is safe and effective in both simple and complex ureter anatomy. The charts of all patients with VUR, who received REVUR in 6 different institutions over a 5-year period, were retrospectively reviewed. Patients with both simple and complex ureter anatomy were included. Patient demographics, surgical variables, and post-operative results were assessed. VUR resolution was defined as either being resolved VUR on voiding cystourethrogram (VCUG) or clinically without symptoms during the follow-up. Fifty-seven patients with median age of 6.9 years (range 4.5-12), receiving REVUR in the study period, were included. Eighteen (31.6%) patients had complex anatomy and included prior failed endoscopic injection (n=13), complete ureteral duplication (n=2), periureteral diverticulum (n=2), ectopic megaureter requiring dismembering (n=1). The median operative time was 155min for unilateral and 211.5min for bilateral repairs. The clinical+radiographic VUR resolution rate was 96.5%. Post-operative complications (Clavien 2) included urinary retention following bilateral repair (n=5, 8.7%), febrile urinary tract infection (UTI) (n=6, 10.5%) and gross hematuria (n=3, 5.2%). Comparative analysis between simple and complex cases showed that REVUR was faster in simple cases in both unilateral [p=0.002] and bilateral repair [p=0.001] and post-operative urinary retention was more frequent in simple cases [p=0.004] and in patients with pre-operative bowel and bladder dysfunction (BBD) [p=0.001] (Table). This series confirmed that the robot-assisted technique was feasible even in cases with complex anatomy using some technical refinements, that justified the longer operative times in both unilateral and bilateral cases. An interesting finding of this study was the correlation emerged between BBD and risk of post-operative urinary retention and VUR persistence. Our results also excluded any significant correlation between complex cases and risk of post-operative urinary retention. The main study limitations included the retrospective and nonrandomized design, the small number of cases and the arbitrary definition of complex anatomy. REVUR was safe and effective for management of VUR in both simple and complex ureter anatomy. Complex REVUR required slightly longer operative times, without significant differences in post-operative mordidity and success rates. Aside from complex anatomy, BBD emerged as the main risk factor associated with surgical failure and post-operative morbidity.

Modified technique for robot-assisted laparoscopic infantile ureteral reimplantation for obstructive megaureter

PurposeTo describe a novel modification of technique to improve efficacy of robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) in infants. Materials and methodsBetween April 2017 and July 2019, sixteen infants with primary obstructive megaureter (POM) (Age range: 4–12 months) underwent robot-assisted ureteral reimplantation were reviewed in this series. In addition to the conventional Lich-Gregoir technique, the detrusor tunnel has been extended to the mobilized anterior bladder wall to guarantee sufficient tunnel length/ureter diameter ratio and avoid ureteral angulation. All patients underwent repeated ultrasound, diuretic renal dynamic imaging and voiding cystourethrography (VCUG) perioperatively and the outcomes were documented. ResultsAll operations were completed with robotic assisted approach without conversion. Bilateral and unilateral reimplantation were respectively performed in two and fourteen patients. The mean operative time was 115.0 ± 19.5 min and the mean blood loss was 10.0 ± 1.8 ml. There were no high-grade complications (III–IV on Clavien-Dindo classification) except for one patient. The distal ureteric diameter was reduced from pre operative 1.7 ± 0.5 to 0.6 ± 0.5 cm 6 months post operatively (p < 0.05). One child (6.3%) required the second reimplantation for stenosis. The overall operative success rate was 94.4% (17 of 18 ureters) with a mean follow-up of 15.9 ± 7.4 months with no flux detected. ConclusionOur preliminary experience suggests that our modified robot-assisted laparoscopic extravesical ureteral reimplantation is feasible in infants with good results.

Development and Validation of a Scoring System for Assessment of Clinical Failure after Pediatric Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation: A Multi-Center Study.

We aimed to develop and validate a scoring system as an objective assessment tool for predicting clinical failure after pediatric robotic extravesical ureteral reimplantation. Data for this multi-institutional retrospective cohort was obtained from two tertiary referral hospitals. We defined clinical failure as incomplete radiographic resolution or post-operative febrile UTI. Patients were stratified into low, intermediate, and high-risk groups according to the score. External validation was performed using the model projected to the external validation cohort. An amount of 115 renal units in the development cohort and 46 renal units in the validation cohort were analyzed. The prediction score was calculated with weighted points to each variable according to their regression coefficient as age (year) + BMI + BBD times 10 + VUR grade times 7 + console time (h) + hospital stay times 6. The C-index of our scoring system was 0.850 and 0.770 in the development and validation cohorts, respectively. Clinical failure was significantly different among risk groups: 0% (low-risk), 3.3% (intermediate-risk), and 22.2% (high-risk) (p = 0.004) in the development cohort. A novel scoring system using multiple pre- and intra-operative variables provides a prediction of children at risk of failure after robotic extravesical ureteral reimplantation.

УСОВЕРШЕНСТВОВАНИЕ МЕТОДА ЭКСТРАВЕЗИКАЛЬНОЙ РЕИМПЛАНТАЦИИ МОЧЕТОЧНИКА

Objective: To optimize the technique of extravesical ureteral reimplantation in experimental animals. Methods: Experiments were carried out on 21 Flanders rabbits. Initially, ureterohydronephrosis (UHN) was modeled by alcoholization of the ureter in its vesical part according to the method of Ya.V. Gudynsky. After 21 days, the animals underwent extravesical ureteral reimplantation using the technique optimized by the team of urologists. Results: The stents were removed endoscopically on the 20th day. In order to exclude vesicoureteral reflux, contrast cystography was performed, in which reflux was not detected. To exclude obstruction, on the 30th, 60th, and 90th days after the operation, an ultrasound scanning of the urinary system was performed, in which the presence of UHN was not noted. On the 90th day, the experimental animals underwent resection of the anastomotic zone for histological examination. It was found that the diameter of the transplanted segment corresponded to the normal size of the rabbit ureter, there was a slight thickening of the ureteric wall, its hypertrophy, and intracellular hyperplasia. Conclusion: The effectiveness and safety of the proposed method of extravesical ureteral reimplantation with antireflux protection has been experimentally proven. Keywords: Ureter, urodynamics, obstruction, ureterohydronephrosis, megaureter.

Outpatient Robotic Surgery in Pediatric Urology: Assessment of Feasibility and Short-Term Safety.

Robotic reconstructive and extirpative procedures have been widely utilized for surgical management of various conditions in pediatric urology. Outpatient laparoscopic surgery has become the standard in cases of orchidopexy, inguinal hernia repair and varicocelectomy. There is a growing body of evidence that robotic surgery for more complex conditions can also be performed in an outpatient setting. The aim of the study was to assess the short-term safety and feasibility of robotic reconstructive and extirpative procedures for various pediatric urological conditions as scheduled outpatient procedures. Demographic information and perioperative data were prospectively collected in an institutional database for all pediatric patients undergoing outpatient robotic surgery from June 2012 to December 2019. Primary outcomes included rates of 30-day complications, emergency room visits and readmissions. A total of 135 pediatric patients underwent robotic procedures in an outpatient setting. The majority underwent pyeloplasty (62) or extravesical ureteral reimplantation (55). Ten patients underwent ureteroureterostomy and 8 patients underwent extirpative procedures (nephrectomy, hemi-nephrectomy). Median age at surgery was 62 months (IQR, 27-99), median weight was 20 kg (IQR, 12-30) and median body mass index was 17 (IQR, 15-18). During the 30-day followup period there were 9 complications (6.7%), of which only 1 (0.7%) was high grade (Clavien-Dindo 3). There were 9 emergency room visits (6.7%) including 5 cases of readmission (3.7%). Robotic reconstructive and extirpative procedures in pediatric urology can be safely performed as scheduled outpatient procedures in the majority of patients, obviating the need for routine inpatient care.

Experience of Maharaj Nakorn Chiang Mai Hospital in extravesical ureteral reimplantation for vesicoureteral reflux in pediatric patients

Objective: The most commonly used technique for vesicoureteral reflux (VUR) treatment in pediatric patients in Maharaj Nakorn Chiang Mai Hospital is extravesical ureteral reimplantation (EUR). This report describes our experience of clinical outcomes of this technique. Materials and Methods: A total of 30 children underwent EUR for unilateral and bilateral VUR between July 2007 and June 2015. We retrospectively reviewed their medical records. Patient characteristics, operative time, duration of catheter drainage, length of postoperative hospital stay, and perioperative complications were evaluated. Results: Twenty-two boys and 8 girls with a mean age of 4.4 years (range, 0.5-14.6) were included in the study. Reflux was graded 1 to 5. Fourteen unilateral and 16 bilateral procedures were performed. A Pfannenstiel incision was implemented in the first 20 cases and inguinal incision in the last 10 cases. Mean operative time was 115.5 minutes. Mean duration of catheter insertion was 5.7 days. Mean length of postoperative hospital stay was 6.1 days and mean estimated blood loss was 28.7 ml. Overall success rate was 90%. One patient (3.3%), developed a post- operative urinary tract infection, while 3 cases had persistent VUR after surgery. Acute urinary retention occurred in 1 patient (3.3%) on postoperative day 4 but following catheterization the patient was able to urinate by day 7. Conclusion: EUR for the treatment of VUR is a simple, safe, and effective procedure. The prevalence of postoperative urinary retention in bilateral reimplantation is low and transient. The inguinal approach is a viable option and as effective as classical procedures.

Robotic Ureteral Reimplantation: Nonrefluxing Intravesical and Extravesical Techniques

Introduction: Nonrefluxing ureteral reimplantation is the gold standard surgical management of patients with symptomatic vesicoureteral reflux (VUR).1,2 Intravesical and extravesical ureteral reimplantation were traditionally performed with an open approach through the Cohen, Lich-Gregoir, Glen-Anderson, and Politano-Leadbetter techniques.3 However, there has been recent adoption of minimally invasive approaches including the use of robotic assistance.1 Moreover, these nonrefluxing ureteral reimplantation techniques have been primarily described in the pediatric population rather than in adults.2 We demonstrate our techniques and describe outcomes of adult patients undergoing nonrefluxing intravesical and extravesical robotic ureteral reimplantation (RUR). Materials and Methods: We reviewed our institution's own robotic ureteral reconstruction database to identify consecutive adult patients with a history of VUR who underwent nonrefluxing intravesical or extravesical RUR between September 2016 and November 2020. Indications for surgery included patients with symptoms of flank pain and/or recurrent infections secondary to VUR. Our primary outcome was surgical success, which we defined as the absence of postoperative flank pain and radiographic absence of VUR on voiding cystourethrogram or obstruction on diuretic renal scan. Before beginning the procedure, all patients underwent cystoscopy, cystogram, and/or retrograde pyelogram. Robotic ports are placed similarly for both techniques through the standard prostatectomy configuration without a fourth robotic port or the right lateral 12 mm assistant port. A 5 or 12 mm assistant port is placed between the camera and the right robotic port. Meticulous dissection of the distal ureter to preserve its fragile blood supply is performed for both techniques. In the robotic intravesical technique, adapted from the Politano-Leadbetter technique, the ureter is redirected through a new supratrigonal hiatus and submucosal tunnel created in a 5:1 ratio.4 The neoureteral orifice (UO) is relocated distally (subtrigonometry) and medial to the orthotopic UO. In the robotic extravesical technique, adapted from the Lich-Gregoir technique, a mucosa sparing extravesical tunnel is created according to the Paquin guidelines with a 5:1 length to diameter ratio.5,6 In patients who have a previous ureteroneocystostomy complicated by reflux symptoms, the existing reimplant site can be left intact and revised with an extravesical tunnel to prevent reflux. Results: Three patients met inclusion criteria. Two patients underwent nonrefluxing extravesical RUR and one patient underwent intravesical RUR. The patient who underwent an extravesical RUR had a history of reimplantation that was complicated by severe reflux-related symptoms. Intraoperatively, the mean estimated blood loss was 50 mL and mean robotic console time was 162 minutes. Postoperatively, none of the patients experienced major (Clavien >2) complications. With regard to surgical success, at a mean follow-up of 20.5 months, all patients were free of urinary tract infections and obstructive flank pain symptoms. In addition, all patients achieved complete resolution of VUR on postoperative voiding cystourethrogram or renal scan. Conclusions: Nonrefluxing intravesical and extravesical RUR may be safely and effectively utilized for surgical management of adult patients with symptomatic VUR. Moreover, the nonrefluxing extravesical RUR can be used to revise select patients with prior reimplantation complicated by symptomatic reflux. S.K., C.O., and M.L. have no competing financial interests. D.D.E. reports a relationship with Intuitive Surgical that includes consulting or advisory and speaking and lecture fees. D.D.E. reports a relationship with Melzi Corp that includes board membership. D.D.E. reports a relationship with Johnson and Johnson that includes consulting or advisory. Accepted for presentation at Mid-Atlantic AUA 2021. Patient Consent Statement: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Music: Music (Gentle Wave by Ketsa) is not copyrighted material and was obtained from a royalty-free source. Runtime of video: 7 mins 14 secs

Laparoscopic extravesical ureteral reimplantation (LEUR) of obstructed megaureters: STEP-BY-STEP video of a simplified approach

In this video we aim to describe step-by-step a simplified surgical technique for the treatment of primary and secondary obstructed megaureters in children by laparoscopic extravesical ureteral reimplantation (LEUR). A transperitoneal approach is used in all cases. The distal ureter is dissected and transected at the level of the stenosis. Detrusor fibers are divided to expose bladder mucosa and the distal ureter is introduced into the bladder to create a valve-like mechanism (modified-Shanfield technique). Between 2016 and 2020, 9 patients underwent LEUR (5 female, 4 male). Mean age at surgery was 31.6 months (SD:22.74) and indications were infection (2), obstruction (3), increase hydronephrosis (2) and decrease in renal differential function (2). The procedure was completed laparoscopically in all cases with a median operative time of 144min (r: 120-160). The postoperative MAG-3 renogram revealed a non-obstructive pattern in 8/9 patients and MCUG demonstrated absence of VUR in all 8/9. With a mean follow-up of 2.4 years (SD:1.4) all are asymptomatic. LEUR by this new simplified technique is a feasible treatment of megaureters associated with good short and long-term results.

Characterizing the Topography of the Vesical Portion of the Inferior Hypogastric Plexus and its Associated Endopelvic Fascial Planes: Informing Nerve‐sparing Ureteric Reimplantation Surgery

Extravesical ureteric reimplantation is an effective treatment for vesicoureteral reflux. Concerningly, when performed bilaterally, it is associated with a 10-15% incidence of postoperative urinary retention and is postulated to be caused by iatrogenic damage to the nearby pelvic autonomic nerves. Unfortunately, an effective nerve-sparing surgical approach is limited by a lack of comprehensive anatomical knowledge of these nerves (i.e., location, distribution, density). Thus, this study aims to investigate the anatomy of the autonomic nerves within the endopelvic fascial planes and in the vicinity of the ureterovesical junction (UVJ), in fresh and ethanol-phenol-fixed human cadavers. To address this, the present study utilized gross dissection to identify the course of the autonomic nerves within the endopelvic fascial planes to contextualize their anatomical position and aid in surgical identification (Objective 1). Subsequently, we sought to examine the position and density of pelvic autonomic nerve fibers in the soft tissue surrounding the UVJ using western blot and semi-quantitative densitometry analysis (Objective 2). Findings from nine specimens (n= 9 cadavers; 8 males, 1 female) revealed a common endopelvic fascial plane including the gonadal vessels, ureters, and hypogastric nerves (from lateral to medial, respectively), that overlays the abdominal aorta. The region posterior to this plane was found to be continuous with the pre-sacral space inferiorly. The fascial plane containing the vas deferens in male specimens was differentiable from this common plane and can be seen intersecting proximal to the UVJ. The characterization of pelvic autonomic nerve fiber density, specifically surrounding the UVJ using western blot analysis, is ongoing. This study provides the first identification of hypogastric nerves (medial), ureters (between) and gonadal vessels (lateral) situated in a common endopelvic fascial plane (n= 9), an inferior continuation of the renal fascia, specifically the internal layers of Gerota's & Zuckerkandle's. Knowledge of these endopelvic fascial planes, paired with ongoing densitometry analysis in Objective 2, will provide the necessary anatomical foundation for future research to further refine nerve-sparing surgical approaches of ureteric reimplantation. Acknowledgements: Kaitlin Marshall, Dale Fournier, Mariyan Jeyarajah, Stephen Renaud, Haley Linklater, Kevin Walker and the UWO anatomy lab donors.

Results of a previously unreported extravesical ureteroneocystostomy technique without ureteral stenting in 500 consecutive kidney transplant recipients.

Urologic complications can still occur following kidney transplantation, sometimes requiring multiple radiological and/or surgical procedures to fully correct the problem. Previously proposed extravesical ureteral reimplantation techniques still carry non-negligible risks of the patient developing urologic complications. About 10 years ago, a new set of modifications to the Lich-Gregoir technique was developed at our center, with the goal of further minimizing the occurrence of urologic complications, and without the need for initial ureteral stent placement. It was believed that an improvement in the surgical technique to minimize the risk of developing urologic complications was possible without the need for stent placement at the time of transplant. In this report, we describe the advantages of this technique (i.e., mobilized bladder, longer spatulation of the ureter, inclusion of bladder mucosa with detrusor muscle layer in the ureteral anastomosis, and use of a right angle clamp in the ureteral orifice to ensure that it does not become stenosed). We also retrospectively report our experience in using this technique among 500 consecutive (prospectively followed) kidney transplant recipients transplanted at our center since 2014. During the first 12mo post-transplant, only 1.4%(7/500) of patients developed a urologic complication; additionally, only 1.0%(5/500) required surgical repair of their original ureteroneocystostomy. Five patients(1.0%) developed a urinary leak, with 3/5 having distal ureteral necrosis, and 1/5 subsequently developing a ureteral stricture. Two other patients developed ureteral stenosis, one due to stricture and one due to ureteral stones. These overall results are excellent when compared with other reports in the literature, especially those in which routine stenting was performed. In summary, we believe that the advantages in using this modified extravesical ureteroneocystostomy technique clearly help in lowering the early post-transplant risk of developing urologic complications. Importantly, these results were achieved without the need for ureteral stent placement at the time of transplant.

Reimplante ureteral extravesical con técnica de Lich Gregoir

Se presenta el caso de una paciente femenina de 55 años de edad, que durante una histerectomía videolaparoscópica, se notó la presencia de orina libre en cavidad abdominal, se llamó a la unidad de urología para evaluación transoperatoria, quienes identificaron sección completa del uréter derecho en la unión ureterovesical. En el mismo tiempo quirúrgico se realizó reimplante ureteral extravesical con técnica de Lich Gregoir por la unidad de urología.

Results of laparoscopic extravesical antireflux operation in vesicoureteral reflux in children

The objective was to improve the results of surgical treatment of vesicoureteral reflux in children, using laparoscopic access. The prospective study was performed in 111 children (137 ureters) with the primary III–IV grade vesicoureteral reflux. The mean age was 34.7 months. The modified laparoscopic antireflux technique was performed on 73 children (91 ureters). We compared the perioperative complications and the medium-term outcome with a group of 38 children (46 ureters) who underwent classical laparoscopic extravesical reimplantation.3 In the modified group, the mean surgery time was 109.8 ± 31.5 minutes for unilateral cases and 176.5 ± 47.6 minutes for bilateral cases; in the classical group, it was 118.6 ± 34.3 and 209.5 ± 51.2 minutes respectively (p &gt; 0.05). Postoperative vesicoureteral reflux had 2 (2.7 %) patients in the main group and 8 (21.1 %) children in the control group (p = 0.002). There was no ureteral obstruction in the both groups. The success rate for ureters was 97.8 % with modified technique versus 82.6 % after classical laparoscopic reimplantation (p = 0.003). Laparoscopic extravesical ureteral reimplantation is a safe and effective surgical procedure. The modified technique may improve the surgical treatment results.

Effectiveness of Ureteric Reimplantation on Non-Refluxing Obstructive Congenital Megaureter

Background: One in ten thousand children born with megaureter. A significant portion of this groups are of obstructed variety and the rest are refluxing ureter. It can cause obstructions and back pressure renal damage. Early diagnosis and treatment can stop deterioration of renal function and prevent complications like renal failure. Definitive treatment is uretero-neocystostomy with or without tailoring the ureter. Objective: Objective of this study was to observe the effectiveness of ureteric reimplantation on non-refluxing obstructive congenital megaureter. To achieve this objective we had observed serum creatinine level pre and postoperatively and assessed structural changes in kidney by ultrasonogram, IVU, MCU and RGP pre and postoperatively. We also observed the split renal function and split GFR of the affected kidney both pre and post operatively. Methods: This was a cross-sectional observational study. This study comprise of 35 cases of congenital non-refluxing obstructed megaureter, who were admitted in BIRDEM General Hospital and multiple other hospitals in Dhaka city from July 2013 to December 2014. Diagnosis was made by intravenous urography (IVU) reveling a dilated lower third or entire ureter with narrow tapering lower end. Obstruction was also confirmed by diuretic Tc99m DTPA scan. A voiding cystourethrogram was obtained to exclude VUR. Those with poor renal function were evaluated by ultrasonography, DTPA scan and retrograde ureteropyelography. Results: Of 35 patients, 20 were male and 15 were female. Age range 2 to 19 years. All patients underwent ureteric reimplantation, with tailoring in 15 cases. Post-operative mean serum creatinine was 0.99±0.34 which showed improvement. Split function in DTPA renogram and split GFR of patient with POM in the affected right side also showed improvement (29.49±4.02 and 29.64±4.86) as well as affected in left side (27.77±4.18 and 28.02±5.31). Conclusion: Ureteral tailoring with an extravesical ureteral reimplantation can be performed safely and effectively for primary obstructive megaureter. It is found that, ureteroneocystostomy ensured free renal drainage and preserved renal function as well as prevented complications and further deterioration. Bangladesh Journal of Urology, Vol. 21, No. 1, January 2018 p 20-24

Robot-assisted laparoscopic extravesical versus conventional laparoscopic extravesical ureteric reimplantation for pediatric primary vesicoureteric reflux: a systematic review and meta-analysis.

To perform a systematic review and meta-analysis comparing the outcomes of robotic-assisted laparoscopic extravesical ureteric reimplantation (RALUR) with conventional laparoscopic extravesical ureteric reimplantation (LEVUR) for primary vesicoureteric reflux in children. We searched the databases to identify all papers of RALUR and LEVUR between 2001 and 2020. Systematic review was performed to identify patient data, age, reflux grades, laterality, duration of surgery, time to discharge, success rate and complications. Heterogeneity was reported with I2 statistics and publication bias was assessed by Doi curve and Luis Furuya-Kanamori index. Pooled data from both groups were compared with Student's t test and Fisher's exact test, wherever appropriate. From a total of 43 articles screened, 28 articles were included (18 RALUR and 10 LEVUR). The I2 statistics for RALUR and LEVUR showed heterogeneity of 86% and 25%, respectively. Both groups had comparable minor publication bias. RALUR had higher proportion of grade 5 VUR (p < 0.001) and bilateral reimplantations (p < 0.001). The success rate of RALUR was significantly lower than that of LEVUR (97.6% vs. 93.4%, p = 0.0018). RALUR took a significantly longer duration for surgery compared to LEVUR, both for unilateral and bilateral cases (p < 0.001). The complication rate was not significantly different: 6.6% for RALUR and 5.35% for LEVUR (p = 0.32). The most common complication in both groups was post-operative urinary retention in bilateral cases. Articles on LEVUR reported more consistent success. RALUR series had higher proportion of grade 5 cases and bilateral reimplantations. RALUR reported longer operative time and lower success compared to LEVUR, with a complication rate comparable to LEVUR.

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.