Extravesical Ureteral Reimplantation Research Articles

Robot-Assisted Vesicovaginal Fistula Repair with Excision of Mesh and Simultaneous Intravesical Ureteral Reimplant

Introduction: Urologic complications from hysterectomy such as vesicovaginal fistula (VVF) and ureteral injury are known to occur at a rate of ∼1%. When a hysterectomy is indicated for uterine prolapse, simultaneous sacrocolpopexy can also result in a different complication, such as mesh erosion. Using the robot-assisted approach has been shown to be a favorable option when the abdominal approach is warranted in the event, ureteral reimplant is needed for ureteral orifices positioned near the fistula tract or a coexistent ureterovaginal fistula. For distal, intramural ureteral strictures, intravesical ureteral excision and mobilization can be performed, obviating the need to perform an extravesical ureteral reimplant. Methods: We present a case of a 48-year-old woman who had a robotic total hysterectomy with sacrocolpopexy performed. She developed a VVF and underwent two failed repairs; one abdominal and one vaginal, with the later causing a distal ureteral stricture not successfully managed with stenting. A robotic VVF repair was performed with an intravesical ureteral reimplant. Results: The patient had a successful repair of her VVF and excision of a distal ureteral stricture with no hydronephrosis nor incontinence. Conclusions: To our knowledge, this is the first report of robot-assisted VVF repair with excision of mesh and intravesical ureteral reimplant. The two repair attempts from her earlier surgeries likely failed secondary to incomplete removal of mesh involved with the fistula tract. The video emphasizes the importance of adherence to strict surgical principles of repair of VVF as historically documented in the literature, but also the importance for complete mesh excision. We introduce a novel surgical option of intravesical ureteral reimplant/mobilization, should the intramural ureter have injury or if it is too close to the fistula tract. The authors disclose that there are no conflicts of interest or obligations. Runtime of video: 7 mins 27 secs

Laparoscopic Extravesical Ureteral Reimplantation (LEVUR): A Multicenter Experience with 95 Cases

Minimally invasive techniques have been used to treat vesicoureteral reflux (VUR) on pediatric patients. The aim of this study is to review the experience of the laparoscopic approach for VUR by the laparoscopic extravesical ureteral reimplantation (LEVUR) Lich-Gregoir technique. We performed a multicentric retrospective study. From 2001 to 2009, 81 pediatric patients with VUR constituting 95 ureteral units underwent LEVUR. Reflux was grade II in 32%, grade III in 55%, and grade IV in 8%. LEVUR was performed successfully on the 81 patients with 95 ureteral units. Mean operative time was 105 minutes for left-sided reimplants, 70 minutes for right sided, and 180 minutes for bilateral reimplants. Mean hospital stay was 1.6 days. Urinary catheter was kept in place for a mean time of 0.5 days. Follow-up was achieved for at least 1 year with regular clinic visits, urinalysis, ultrasound, and voiding cystourethrogram. Four patients (4.2%) had evidence of recurrent VUR in a follow-up of 6 to 36 months after antireflux surgery. Although new endoscopic techniques have been widely available for VUR, they have a lower success rate and might require multiple attempts before success. We report that LEVUR has an acceptable success rate (95.8%) and durability compared with open and endoscopic procedures.

Ureteral Advancement in Patients Undergoing Laparoscopic Extravesical Ureteral Reimplantation for Treatment of Vesicoureteral Reflux

Laparoscopic extravesical ureteral reimplantation for vesicoureteral reflux has gained acceptance as a feasible treatment associated with minimal morbidity. However, ureteral advancement with this technique has not been attempted. We examined the usefulness of ureteral advancement via laparoscopy. A total of 30 patients with 51 refluxing ureters underwent laparoscopic extravesical ureteral reimplantation for treatment of vesicoureteral reflux between August 2009 and September 2011. Mean ± SD patient age was 60.8 ± 48.6 months. During the procedure 15 patients underwent ureteral advancement (advancement group), while 15 did not (nonadvancement group). We compared operative times and postoperative rates of urinary tract infections and persistent reflux between the groups. There was no significant difference in operative times in unilateral (mean ± SD 110 ± 25 vs 125 ± 42 minutes) and bilateral cases (mean ± SD 214 ± 52 vs 203 ± 40 minutes) between the nonadvancement vs advancement groups. All patients underwent voiding cystourethrography 3 to 4 months postoperatively. Reflux resolution rate for ureters was significantly higher in the advancement group (100%) than in the nonadvancement group (85%, p <0.05). No patient in the advancement group had postoperative urinary tract infection. Fixation of the ureter with the bladder muscularis at the proximal limit of the detrusor defect and/or a percutaneous hitch stitch placed in the ventral side of the proximal limit of the detrusor defect facilitated ureteral advancement. Ureteral advancement is a simple and feasible procedure in laparoscopic ureteral extravesical reimplantation and may improve the resolution rate of vesicoureteral reflux.

1225 URETERAL STENTING IS UNNECESSARY DURING ROBOTIC-ASSISTED LAPAROSCOPIC EXTRAVESICAL URETERAL REIMPLANTATION FOR PRIMARY VESICOURETERAL REFLUX

INTRODUCTION AND OBJECTIVES: Robotic-assisted laparoscopic (RAL) surgery in children is an emerging, minimally invasive alternative to open surgery in children, such as for the surgical management of vesicoureteral reflux (VUR) via extravesical (EV) ureteral reimplantation. Previous reports have described the use of a ureteral stent during and after this robotic procedure. We previously presented our simplified (stent-less) technique. The purpose of this study is to review our experience of RAL EV ureteral reimplantation performed without the use of a ureteral stent. METHODS: 50 pediatric patients with primary VUR (40 unilateral and 10 bilateral for a total of 60 refluxing units) underwent RAL ureteral reimplantation surgery via an extravesical technique. An institutional review board-approved retrospective chart review was performed to collect patient demographic and perioperative data. RESULTS: The operative success rate, defined as complete resolution of the VUR on the voiding cystourethrogram (VCUG) at the 4-month mark after surgery, was 97% (58/60), which is equivalent to those of historical open surgery series. The median age at surgery was 5.0 years (1.0 – 12.0) and the VUR grade distribution was grades: I 1, II 15, III 27, IV 15, V 2. The median length of hospital stay was 1.3 days (0.9 19.3) and the estimated blood loss was minimal. The median follow-up was 22.8 months (1.0 – 31.0). One patient continued to be observed with postoperative non-dilating VUR and the other patient had improvement from grade IV to II-III, but required open re-operation for a paraureteral diverticulum. After overnight catheterization postoperatively, 3 patients (6%) required re-catheterization postoperatively, with resolution of the urinary retention within 2 weeks. Post-operative mild to moderate hydronephrosis (HN) was noted in 17 of the 60 kidney units (28%) at the one-month mark post-operatively, but all of the cases of HN resolved at a median time of 4 months (3 11) without the need for intervention. CONCLUSIONS: RAL EV ureteral reimplantation without ureteral stenting achieves comparable efficacy and safety of open ureteral reimplantation surgery without the use of ureteral stents. Post-operative hydronephrosis after RAL EV reimplantation surgery is usually temporary, self-limited, and does not require intervention.

619 MODIFICATIONS IN TECHNIQUE LEADING TO IMPROVED SUCCESS OF ROBOTIC EXTRAVESICAL URETERAL REIMPLANATION

INTRODUCTION AND OBJECTIVES: While initial series have reported high failure rates, success of robotic assisted laparoscopic extravesical ureteral reimplantation (RALUR) has now approached that of open surgery. Improved success is often accredited to increased experience without indicating any improvement to technique. We review the outcomes of our first patients to have RALUR and analyze success based on changes in our technique that have occurred over time. METHODS: Between November 2008 and June 2011, a single surgeon, MSG, performed RALUR on a total of 22 patients (35 ureters) with vesicoureteral reflux (VUR). Retrospective analysis of our prospectively maintained database was performed. Only patients with successful completion of RALUR and postoperative voiding cystourethrogram (VCUG) were included in analysis. Success was defined as complete resolution of VUR on VCUG. The surgical technique for RALUR and subsequent modifications were placed into the following categories: Use of simple interrupted stitches and detrussoraphy length (DL) of 3 cm (1), Running stitch with DL of 4 cm (2), Running stitch, incorporation of ureteral adventitia with detrussoraphy closure, and DL of 5 cm (3) (Figure1). RESULTS: 20 patients (8 unilateral and 12 bilateral ureters) fit inclusion criteria. On preoperative VCUG, 12 ureters had grade 3 and 18 ureters grade 4 VUR. In patients with bilateral VUR, one had unilateral grade 1 and one had unilateral grade 2 VUR. Average age at surgery was 5.2 years (range 2.8 – 7.9 years). Mean operative time was 193 minutes for unilateral and 216 minutes for bilateral surgery. Average length of stay was 2.2 days (range 1 to 4 days). One patient was discharged with a catheter for transient urinary retention. No patient required readmission after discharge. Overall, resolution of VUR was seen in 25 of 32 ureters (78%). Resolution of VUR based on surgical technique was 8 of 13 ureters (62%), 6 of 8 ureters (75%), and 11 of 11 ureters (100%) for techniques 1, 2, and 3 respectively. Average follow up was 337 days (range 98 to 889 days). De novo postoperative hydronephrosis was seen in 9 ureters (28%) and resolved in all cases. CONCLUSIONS: Improvement in surgical technique including use of a running stitch, incorporation of ureteral adventitia into closure of detrussoraphy and increasing DL have helped in improving our success of RALUR.

Laparoscopic extravesical ureteral reimplantation with diverticulectomy for refluxing ureters associated with paraureteral diverticula

Laparoscopic extravesical ureteral reimplantation with diverticulectomy for refluxing ureters associated with paraureteral diverticula

Does Hydronephrosis After Extravesical Ureteral Reimplantation Deteriorate Renal Function?

We analyzed whether newly developed or aggravated hydronephrosis deteriorates differential renal function after extravesical ureteral reimplantation. We performed extravesical ureteral reimplantation in 93 patients with unilateral vesicoureteral reflux between January 2006 and December 2009. Excluding 3 patients with other combined disease, a retrospective cohort analysis of 90 consecutive patients was conducted. We performed ultrasonography before and 1 month after extravesical ureteral reimplantation, and dimercapto-succinic acid scan before and 6 months after extravesical ureteral reimplantation. Of the patients 83 underwent final dimercapto-succinic acid scan at 6 months postoperatively. We analyzed the preoperative studies and perioperative parameters to evaluate the factors affecting newly developed or aggravated hydronephrosis at 1 month, and decrease in differential renal function at 6 months after extravesical ureteral reimplantation. Newly developed or aggravated hydronephrosis was observed in 25 patients (28.4%) 1 month after extravesical ureteral reimplantation. Younger age at surgery was a risk factor (p = 0.003). Of the patients 23 showed improvement on ultrasound 6 months postoperatively. In 12 patients (15.7%) a decrease in differential renal function of more than 5% was observed 6 months postoperatively. Preoperative parenchymal reduction on dimercapto-succinic acid scan was the only significant factor (p = 0.008). There was no correlation between newly developed or aggravated hydronephrosis and final decrease in differential renal function (p >0.999). Although newly developed or aggravated hydronephrosis after extravesical ureteral reimplantation is common, especially in younger patients, it is transient and does not affect differential renal function. A postoperative decrease in differential renal function without further urinary tract infection could develop when there is a parenchymal reduction on preoperative dimercapto-succinic acid scan.

Experience with robot-assisted laparoscopic surgery of the lower ureteral segment in adults.

Open reconstructive surgery of the lower ureteral segments in adults requires wide exposure as the basic prerequisite for such complex procedures. Thus, open surgical reconstruction in this area is an invasive procedure for the patient. Nevertheless, during the last few years robot-assisted laparoscopic techniques have emerged and have also already been used successfully for minimally invasive complex reconstructive procedures in urology. We present the medical histories, descriptions of the surgical procedures, and the postoperative data for adult patients undergoing robot-assisted surgery of the lower ureteral segments. Between July 2009 and July 2010, three surgeons performed nine robot-assisted reconstructive operations of the lower ureteral segments including five segmental ureteral resections combined with the psoas hitch procedures in three cases and, in addition, a Boari flap in one of them, one ureteric stricture resection with end-to-end anastomosis, one extravesical ureteral reimplantation because of vesicorenal reflux, one bilateral intravesical ureteral reimplantation because of bilateral ureteral ectopia, and one ureterolysis with omental wrap in a patient with pelvic endometriosis. We observed no intraoperative complications. Postoperative complications occurred in six patients (Clavien Grad I n=1, II n=4, IVa n=1). During a median follow up of five months all affected renal units remained asymptomatic and were free from hydronephrosis. Our data illustrate that robot-assisted surgery of the lower ureter is feasible and support the growing evidence from the literature that it can be successfully used for complex ureteric reconstruction.

Robotic-assisted laparoscopic extravesical ureteral reimplantation: An initial experience

ObjectiveThere are many emerging techniques using robotic-assisted laparoscopy (RAL) in pediatrics. We performed a retrospective review of our first patients who underwent RAL extravesical ureteral reimplantation. Materials/MethodsBetween October 2007 and May 2010, a single surgeon performed RAL extravesical ureteral reimplantation in 17 patients. Six patients underwent bilateral reimplantation, resulting in a total of 23 ureters repaired. There were 16 females and 1 male (mean age 6.23 years). Four patients had prior Deflux injection. Postoperative reflux status was assessed by voiding cystourethrogram. Results16 patients (22 ureters) were compliant with follow up. Mean follow up was 11.5 months. Mean anesthetic time was 3 h, 57 min for unilateral and 4 h, 45 min for bilateral repair. Complete vesicoureteral reflux resolution was seen in 20 ureters (90.9%), downgrading in one ureter, and unchanged persistent reflux in one ureter. Average hospital stay was 1.3 days. No patients required postoperative catheterization at discharge. ConclusionsOutcomes for new procedures can be variable and unpredictable as the technique evolves. Given the high success rates of open reimplantation, a minimally invasive technique must show comparable results if it is to play a continuing role. Our initial results are encouraging, but prospective analyses are required to outline the future role of RAL ureteral reimplantation.

Extravesical Implantation of a Continent Catheterizable Channel

Extravesical ureteral reimplantation provides results equivalent to those of the open technique with the advantage of less postoperative morbidity from a large cystotomy. Surgical series describing the technique and efficacy of extravesical implantation of continent catheterizable channel are lacking. We reviewed our results to determine the efficacy of this technique with an emphasis on continence and the need for revision. We reviewed the records of 394 patients who underwent a bladder continent catheterizable channel procedure from 1999 to 2009. Operative records describing an extravesical technique were noted. Briefly, a 3 to 6 cm incision is made in the detrusor and seromuscular flaps are created. The continent catheterizable channel is laid in the tunnel and the flaps are brought anterior to the channel and sutured to each other. Fixation of the bladder wall to the abdominal wall preserves tunnel length and minimizes the risk of angulation. The type of continent catheterizable channel, stomal continence and the need for revision were recorded. The extravesical implantation technique of a continent catheterizable channel was done in 84 of 394 patients (21%). The channel was an appendix in 47 cases and Monti ileovesicostomy in 37. Stomal continence was achieved in 79 of 84 cases (94%). At a mean followup of 45 months 22 patients (26%) required a total of 30 surgical revisions, of which most were skin level or endoscopic procedures at a mean of 26 months after channel creation. The extravesical technique for continent catheterizable channel implantation is effective. If intravesical surgery is not necessary, avoidance of a large cystotomy and longer operative time may expedite postoperative recovery when using an extravesical implantation technique to create a continent catheterizable channel.

Comparison of the Learning Curve and Outcomes of Robotic Assisted Pediatric Pyeloplasty

We compared the learning curve and outcomes in children undergoing robotic assisted laparoscopic pyeloplasty during the initiation of a robotic surgery program compared to the benchmark of open pyeloplasty. The records of our first consecutive 33 children undergoing robotic assisted laparoscopic pyeloplasty from 2006 to 2009 were retrospectively reviewed and compared to those of age and gender matched children who underwent open repair done by senior faculty surgeons before the initiation of our robotic surgery program. We compared operative time, complications, postoperative pain, length of stay and surgical success for 2 surgeons who adopted the robotic approach at an academic teaching institution. We found no significant differences in length of stay, pain score or surgical success at a median followup of 16 months. The number of complications was similar and they tended to be early and technical in the robotic assisted laparoscopic pyeloplasty group. Overall average operative time was 90 minutes longer (38%) for robotic assisted laparoscopic pyeloplasty (p <0.004). When evaluated chronologically, there was evidence of a learning curve. After 15 to 20 robotic cases overall operative times for robotic assisted laparoscopic cases was consistently within 1 SD of our average open pyeloplasty time with no significant difference in overall operative time (p = 0.23). Of the decrease in overall operative time 70% was due to decreased pyeloplasty time rather than peripheral time. There was similar safety and efficacy with robotic assisted laparoscopic pyeloplasty, although complications tended to be technical and early in our initial experience. Operative time decreased with experience and after 15 to 20 cases it was similar to that of open pyeloplasty with similar outcomes and surgical success.

The inguinal approach to extravesical ureteral reimplantation is safe, effective, and efficient

Introduction Minimally invasive surgery implies a percutaneous or endoscopic approach rather than an incision, regardless of size. However, open approaches to various procedures using a mini-incision should assume the same appellation. We report our experience with extravesical ureteral reimplant (EVR) performed through an inguinal mini-incision. Materials and methods Patient characteristics of age, gender, and reflux grade were obtained, and outcomes of recurrent urinary tract infection, time of surgery, time of hospitalization and radiographic resolution were assessed. The technique involved a 2 cm incision made in the lowest inguinal skin crease, standard hernia exposure, opening of the floor of the inguinal canal to isolate the ureter, detrussorhaphy. Results 30 girls and 15 boys with a mean age of 64 months (range 20–180), and mean followup of 18 months (range 3–36) underwent unilateral inguinal mini-incision EVR. Reflux grades represented were 7, 13, 18, 5, and 2 for Grades I through V respectively. Common sheath reimplantations were performed in twelve duplicated systems, and tapering performed in three patients. The average time of surgery was 75 min. All but 2 patients were discharged within 24 h; postoperative imaging was normal in all cases. Three patients had febrile UTIs following discontinuation of prophylactic antibiotics. Conclusion The inguinal approach to EVR is safe, effective, efficient, and well-tolerated. Through several maneuvers learned as the experience with EVR grew, we present a realizable approach to minimally invasive ureteral reimplantation with application in most pediatric urologic practice.

Robotic Assisted Laparoscopic Ureteral Reimplantation in Children: Case Matched Comparative Study With Open Surgical Approach

Surgical treatment may be required in some patients with vesicoureteral reflux. With the recent development of robotic assistance, laparoscopic treatment of vesicoureteral reflux has gained popularity. We sought to evaluate our initial experience with pediatric robotic assisted laparoscopic intravesical and extravesical ureteral reimplantation, and to compare outcomes with the open technique. A retrospective chart review was performed on all patients who underwent robotic assisted laparoscopic ureteral reimplantation between 2007 and 2010. Comparisons were made with a case matched cohort of patients who underwent the open technique. The groups were compared using t tests for numerical variables and chi-square comparisons or Fisher's exact test for categorical variables. A Kaplan-Meier model was used to compare success rates. A total of 19 patients underwent intravesical and 20 underwent extravesical robotic assisted laparoscopic ureteral reimplantation during the study period. They were compared to 22 patients undergoing intravesical and 17 undergoing extravesical open ureteral reimplantation. Although the robotic assisted approach was associated with a longer operative time (p <0.001), children undergoing intravesical robotic assisted reimplantation had a shorter duration of urinary catheter drainage, fewer bladder spasms and a shorter hospital stay compared to those undergoing the intravesical open technique (p <0.01). There were no significant differences in these parameters when comparing extravesical robotic assisted reimplantation to the extravesical open technique. Overall success rates were similar among patients who underwent robotic assisted laparoscopic ureteral reimplantation and open reimplantation (p >0.5). Robotic assisted laparoscopic ureteral reimplantation offers similar success rates to the gold standard, open ureteral reimplantation. Future large scale studies will be required to define further the costs and benefits of robotic assisted laparoscopic ureteral reimplantation in the surgical treatment of vesicoureteral reflux.

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.

579 DURABILITY OF ANTI-REFLUX EFFECT OF URETERAL REIMPLANTATION FOR PRIMARY VESICOURETERAL REFLUX: ANALYSIS OF FINDINGS ON LONG-TERM CYSTOGRAPHY

You have accessJournal of UrologyPediatrics: Imaging/Infections & Vesicoureteral Reflux1 Apr 2011579 DURABILITY OF ANTI-REFLUX EFFECT OF URETERAL REIMPLANTATION FOR PRIMARY VESICOURETERAL REFLUX: ANALYSIS OF FINDINGS ON LONG-TERM CYSTOGRAPHY Katherine Hubert, Paul Kokorowski, Lin Huang, Michaella Prasad, Ilina Rosoklija, Alan Retik, and Caleb Nelson Katherine HubertKatherine Hubert Boston, MA More articles by this author , Paul KokorowskiPaul Kokorowski Boston, MA More articles by this author , Lin HuangLin Huang Boston, MA More articles by this author , Michaella PrasadMichaella Prasad Boston, MA More articles by this author , Ilina RosoklijaIlina Rosoklija Boston, MA More articles by this author , Alan RetikAlan Retik Boston, MA More articles by this author , and Caleb NelsonCaleb Nelson Boston, MA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1389AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The results of open ureteral reimplantation (UR) for primary vesicoureteral reflux (VUR) are excellent. However, there have been few studies documenting the long-term durability of UR results. This is particularly relevant for comparisons with results of endoscopic treatment. We sought to describe long-term cystography (LTC) results among children with a history of successful UR for primary VUR. METHODS We performed a retrospective chart review of all patients with primary VUR who underwent successful UR at our institution between January 1990 and December 2002. Successful UR was defined as absence of VUR (grade 0) into the reimplanted ureter(s) on routine screening cystogram within 6 months of surgery. We then analyzed those patients with successful UR to identify those who underwent LTC (RNC or VCUG performed at least 1 year after UR, and prior to any subsequent anti-reflux procedures). We reviewed LTC results with the primary outcome being the presence or absence of recurrent VUR into the reimplanted ureter(s). RESULTS We identified 764 patients who underwent successful UR for primary VUR, of whom 59 (7.7%) had a subsequent LTC. Among the LTC group, 50 (84.8%) were female. Initial (pre-operative) clinical presentation was UTI in 53 (90%), prenatal hydronephrosis in 4 (7%), one incidental diagnosis and one sibling screen. Preoperative VUR grade was grade ≤II in 44% of the ureters, grade III in 35%, and grade IV–V in 21%. Median age at UR was 3.5 years (IQR: 1.3–6.2 years). Extravesical UR was performed in 14 (23.7%), intravesical UR in 45 (76.3%), and ureteral tapering was required in 5 (8.5%). UR was unilateral in 40 (68%) and bilateral in 19 (32%); a total of 78 ureters were reimplanted. LTC was performed at a median of 41.3 months after UR (IQR: 20–65 months). Indication for LTC was UTI in 43%, routine follow-up in 22%, and other clinical indications in 35%. Long-term cystography results showed that the recurrence rate of VUR was 0%; of the 78 reimplanted ureters, 100% (95% CI: 95.4–100) had no VUR (grade 0). CONCLUSIONS The anti-reflux effect of UR for primary VUR is durable. Even among this selected, high-risk sample, many of whom had clinical indications for cystography that increase the likelihood of recurrent VUR, we observed no VUR recurrences at a median of 3.4 years after surgery. Thus, it is reasonable to conclude that the long-term durability of the successful UR for primary VUR is excellent. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e233-e234 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Katherine Hubert Boston, MA More articles by this author Paul Kokorowski Boston, MA More articles by this author Lin Huang Boston, MA More articles by this author Michaella Prasad Boston, MA More articles by this author Ilina Rosoklija Boston, MA More articles by this author Alan Retik Boston, MA More articles by this author Caleb Nelson Boston, MA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Intracorporeal tapering of the ureter for distal ureteral stricture before laparoscopic ureteral reimplantation.

To present our experience of laparoscopic ureteral reimplantation using intracorporeal ureteral tapering for management of distal ureteral stricture. Between April 2005 and October 2008, six patients, including 3 children and 3 adults, underwent laparoscopic modified Lich-Gregoir type extravesical ureteral reimplantation for distal ureteral stricture. Significant dilatations of proximal segment in these patients were repaired with intracorporeal ureteral tapering. Stricture etiologies were congenital ureterovesical megaureter and iatrogenic gynecologic injury in 4 and 2 patients, respectively. Mean age of the patients was 29.3 years (range, 2 to 62 years). Mean operation time and hospital stay was 185 minutes (range, 150 to 240 minutes) and 4 days (range, 2 to 6 days), respectively. No significant complications were noted intra-operatively. Surgical procedure was performed in all the subjects laparoscopically and no conversion to open surgery happened. Postoperatively, 2 patients were complicated with febrile urinary tract infection that were managed medically. No urinary leakage occurred in early postoperative period. All the patients had patent ureterovesical junction anastomosis in follow-up imaging and recurrence of obstruction was noted in no cases. Two patients (33.3%) developed grade II vesicoureteral reflux. Laparoscopic ureteral reimplantation with intracorporeal tapering of distal segment may be performed safely in management of patients with distal ureteral stricture and severe dilatation of proximal segment.

250 Consecutive Unilateral Extravesical Ureteral Reimplantations in an Outpatient Setting

Unilateral extravesical ureteral reimplantation is comparable to intravesical procedures and more effective than subureteral injection to resolve vesicoureteral reflux. Initial reports showed that the procedure could be feasibly done on an outpatient basis. We present further data on a large series of consecutive, planned, outpatient unilateral extravesical ureteral reimplantations. A total of 250 consecutive patients underwent scheduled outpatient unilateral extravesical ureteral reimplantation. We retrospectively reviewed their records. Patient data were collected on reflux laterality and grade, operative time, hospital stay, complications, need for rehospitalization and resolution rate on radiography 1 month postoperatively. A total of 209 females (84%) and 41 males (16%) underwent planned outpatient extravesical ureteral reimplantation, including on the left side in 158 (63%) and on the right side in 92 (37%). Mean reflux grade was 3.2 with grades II to V in 64 (26%), 96 (38%), 74 (30%) and 16 cases (7%), respectively. Average operative time was 63 minutes and average length of stay, defined as time from initial admission in to discharge home, was 6.2 hours (range 3 to 10 hours). Short-term and late complications occurred in 9 (3.6%) and 8 patients (3.2%), respectively. Extravesical ureteral reimplantation for unilateral vesicoureteral reflux may be consistently done on an outpatient basis with a reasonable complication rate and a low postoperative hospital admission rate.

Early Experience of Robotic-Assisted Reconstructive Operations in Pediatric Urology

Laparoscopic pyeloplasty and ureteric reimplantation are complex urologic operations requiring delicate surgical skill. The use of a robot may provide benefits in performing these reconstructive operations. In this article, we report our early experience in the use of the robot in pediatric urologic operations. Children who underwent robotic-assisted reconstructive urologic operations were reviewed and analyzed. From November 2005 to April 2008, 8 children underwent robotic-assisted reconstructive urologic operations. Three children had extravesical ureteral reimplantation performed for vesicoureteric reflux (VUR), and 5 children had pyeloplasty performed for pelvic-ureteric junction obstruction. There was no conversion to open procedure and no intraoperative complication. The operative time ranged from 105 to 420 minutes (mean, 219). Postoperatively, 1 patient had urinary retention and 1 patient had postoperative fever. Hospital stay ranged from 3 to 10 days (mean, 4.8). Mean follow-up time was 38 months (range, 17-46). VURs were resolved for the 2 children with simple VUR and was downgraded for the child with duplex kidney. All patients who underwent pyeloplasty showed satisfactory urinary drainage after the operation. From this early experience, robotic-assisted urologic operations in children were safe and feasible. It was particularly useful in reconstructive operations that required precise suturing, such as ureteric reimplantation and pyeloplasty.

Robot-Assisted Laparoscopic Nephrectomy and Contralateral Ureteral Reimplantation in Children

Robot-assisted laparoscopic surgery (RALS) has expanded the role for minimally invasive surgery within pediatrics. RALS may be particularly beneficial for the treatment of children with a refluxing nonfunctioning renal moiety and contralateral vesicoureteral reflux. In this report, we describe a single RALS procedure, which includes both nephrectomy or partial nephrectomy, and contralateral extravesical ureteral reimplantation (EVUR). A retrospective review was performed of four patients who underwent RALS nephrectomy/partial nephrectomy and concurrent EVUR in one setting. Procedures were performed by a single surgeon using a robot-assisted laparoscopic approach. Four ports were used in a transperitoneal approach with patient positioning changed without moving the robotic system between the nephrectomy and reimplant. We described the technique and assessed its safety and efficacy. All cases were treated with the single RALS approach. Mean patient age was 2.3 years. Three patients underwent a nephrectomy and one a lower pole partial nephrectomy. The mean estimated blood loss was 16 mL, mean operative time was 291 minutes, and mean length of stay was 2.3 days. There was one case of postoperative ureteral obstruction that was treated with 3 weeks of ureteral stenting without further sequela. Overall, the mean follow-up time was 21 months and follow-up renal ultrasonographs and radionuclide cystograms were normal in all patients. A single RALS procedure that combines nephrectomy/partial nephrectomy and EVUR offers a novel approach to a clinical dilemma that often requires two operations. In this small series, RALS was safe and efficacious. We recommend routine Double-J stenting for the solitary reimplanted ureter.

Laparoscopic ureteric reimplantation of a single-system ectopic ureter in a girl: A rarity

A 14-year-old girl presented with continuous dribbling of urine along with normal voiding pattern since childhood. Cystourethroscopy showed absence of right ureteric opening, and vaginoscopy showed right ureter opening into vaginal vault. Radiological images showed small right kidney with normal excretory function with single-system ectopic ureter. Patient underwent laparoscopic transperitoneal extravesical ureteric reimplantation. At 3 months’ follow-up, intravenous urography (IVU) and micturating cystourethrogram (MCU) showed no obstruction and reflux.