Extravesical Ureteral Reimplantation Research Articles

Prospective multicenter study on robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV): Outcomes and complications

Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is a minimally invasive alternative to open surgery. We have previously reported retrospective outcomes from our study group, and herein provide an updated prospective analysis with a focus on success rate, surgical technique, and complications among surgeons who have overcome the initial learning curve. To assess the safety and efficacy of RALUR-EV in children, among experienced surgeons. We reviewed our prospective database of children undergoing RALUR-EV by pediatric urologists at eight academic centers from 2015 to 2017. Radiographic success was defined as absence of vesicoureteral reflux (VUR) on postoperative voiding cystourethrogram. Complications were graded using the Clavien scale. Univariate regression analysis was performed to assess for association among various patient and technical factors and radiographic failure. In total, 143 patients were treated with RALUR-EV for primary VUR (87 unilateral, 56 bilateral; 199 ureters). The majority of ureters (73.4%) had grade III or higher VUR preoperatively. Radiographic resolution was present in 93.8% of ureters, as shown in the summary table. Ureteral complications occurred in five ureters (2.5%) with mean follow-up of 7.4 months (SD 4.0). Transient urinary retention occurred in four patients following bilateral procedure (7.1%) and in no patients after unilateral. On univariate analysis, there were no patient or technical factors associated with increased odds of radiographic failure. We report a radiographic success rate of 93.8% overall, and 94.1% among children with grades III-V VUR. In contemporary series, alternate management options such as endoscopic injection and open UR have reported radiographic success rates of 90% and 93.5% respectively. We were unable to identify specific patient or technical factors that influenced outcomes, although immeasurable factors such as tissue handling and intraoperative decision-making could not be assessed. Ureteral complications requiring operative intervention were rare and occurred with the same incidence reported in a large open series. Limitations include lack of long-term follow-up and absence of radiographic follow-up on a subset of patients. Radiographic resolution of VUR following RALUR is on par with contemporary open series, and the incidence of ureteral complications is low. RALUR should be considered as one of several viable options for management of VUR in children.

VESICOURETERAL REFLUX

Objectives: The objective of our study is to compare the extravesical andintravesical ureteric reimplantation for the treatment of bilateral vesicoureteral reflux in children.Period: April 2013 and July 2016. Setting: Urology Department of Mayo Hospital, Lahore.Methodology: 66 children diagnosed with primary vesicoureteral reflux and undergoingureteric reimplantation. The Cohen cross-trigonal reimplantation (intravesical) and modifiedLich-Gregoir procedure (extravesical) were performed on two separate groups Group IRand group ER. The following parameters were compared: postoperative duration of stay inthe hospital, hematuria and bladder spasm. Frequency of hematuria, bladder spasm andaverage duration of stay in the hospital were compared in both group. Mean and standarddeviation was calculated for age, gender and duration of surgery in both groups.). Chi squaretest was applied to check the association of outcome variables with demographical variablesand duration of surgery. Results: These 100% (n=66) patients were divided into 2 groupsequally, 33 in each, i.e. group ER and group IR. The mean age and duration of surgery ofthe patients of group ER were 13.78±2.83 years, 102.45±4.13 minutes respectively. Whilethe mean age and duration of surgery of the patients of group IR was 30.33±4.58 years and119.7±10.70 minutes respectively (Table-II).The main outcome variables of this study werethe hospital stay, postoperative bladder spasm and hematuria. The mean hospital stay of thepatients of group ER and group IR was 4.30±1.35 days and 5.84±1.0 respectively (Table-II).It was observed that bladder spasm in group ER and group IR was 39.4% (n=13) and 54.5%(n=18) respectively (Figure-1). It was also observed that hematuria in group ER and group IRwas 36.4% (n=12) and 48.5% (n=16) respectively (Figure-2). Conclusion: The observation ofthis study concludes that extravesical ureteric reimplantation has an edge over conventionalprocedure of intravesical ureteric approach. Intravesical procedure has disadvantages of morefrequency of postoperative complications like, hospital stay, bladder spasms and hematuria.

EXTRAVESICAL VERSUS INTRAVESICAL URETERIC REIMPLANTATION IN CHILDREN

Objectives: The objective of our study is to compare the extravesical andintravesical ureteric reimplantation for the treatment of bilateral vesicoureteral reflux in children.Period: April 2013 and July 2016. Setting: Urology Department of Mayo Hospital, Lahore.Methodology: 66 children diagnosed with primary vesicoureteral reflux and undergoingureteric reimplantation. The Cohen cross-trigonal reimplantation (intravesical) and modifiedLich-Gregoir procedure (extravesical) were performed on two separate groups Group IRand group ER. The following parameters were compared: postoperative duration of stay inthe hospital, hematuria and bladder spasm. Frequency of hematuria, bladder spasm andaverage duration of stay in the hospital were compared in both group. Mean and standarddeviation was calculated for age, gender and duration of surgery in both groups.). Chi squaretest was applied to check the association of outcome variables with demographical variablesand duration of surgery. Results: These 100% (n=66) patients were divided into 2 groupsequally, 33 in each, i.e. group ER and group IR. The mean age and duration of surgery ofthe patients of group ER were 13.78±2.83 years, 102.45±4.13 minutes respectively. Whilethe mean age and duration of surgery of the patients of group IR was 30.33±4.58 years and119.7±10.70 minutes respectively (Table-II).The main outcome variables of this study werethe hospital stay, postoperative bladder spasm and hematuria. The mean hospital stay of thepatients of group ER and group IR was 4.30±1.35 days and 5.84±1.0 respectively (Table-II).It was observed that bladder spasm in group ER and group IR was 39.4% (n=13) and 54.5%(n=18) respectively (Figure-1). It was also observed that hematuria in group ER and group IRwas 36.4% (n=12) and 48.5% (n=16) respectively (Figure-2). Conclusion: The observation ofthis study concludes that extravesical ureteric reimplantation has an edge over conventionalprocedure of intravesical ureteric approach. Intravesical procedure has disadvantages of morefrequency of postoperative complications like, hospital stay, bladder spasms and hematuria.

Robot-assisted extravesical ureteral reimplantation (revur) for unilateral vesico-ureteral reflux in children: results of a multicentric international survey.

This multicentric international retrospective study aimed to report the outcome of robot-assisted extravesical ureteral reimplantation (REVUR) in patients with unilateral vesico-ureteral reflux (VUR). The medical records of 55 patients (35 girls, 20 boys) underwent REVUR in four international centers of pediatric robotic surgery for primary unilateral VUR were retrospectively reviewed. Patients' average age was 4.9years. The preoperative grade of reflux was III in 12.7%, IV in 47.3% and V in 40%. Twenty-six patients (47.3%) presented a loss of renal function preoperatively and 10 (18.1%) had a duplex system. Average robot docking time was 16.2min (range 5-30). Average total operative time was 92.2min (range 50-170). No conversions or intra-operative complications were recorded. All patients had a bladder Foley catheter for 24h post-operatively. Average hospital stay was 2days (range 1-3). Average follow-up length was 28months (range 9-60). We recorded three (5.4%) postoperative complications: 1 small urinoma resolved spontaneously (II Clavien) and 2 persistent reflux, only one requiring redo-surgery using endoscopic injection (IIIb Clavien). REVUR is a safe and effective technique for treatment of primary unilateral VUR. The procedure is easy and fast to perform thanks to the 6° of freedom of robotic arms. The learning curve is short and it is useful to begin the robotics experience with a surgeon expert in robotic surgery as proctor on the 2nd robot console. The high cost and the diameter of instruments remain the main challenges of robotics applications in pediatric urology.

Unilateral extravesical ureteral reimplantation via inguinal incision for the correction of vesicoureteral reflux: a 10-year experience.

ABSTRACTIntroduction and Objective:Multiple options exist for the surgical management of vesicoureteral reflux (VUR). We report on our 10-year experience using the inguinal approach to extravesical ureteral reimplantation (EVR).Materials and Methods:Patient characteristics of age, gender, and reflux grade were obtained and outcomes of operative time, hospital stay, and radiographic resolution were assessed.Results:71 girls and 20 boys with a mean age of 74 months (range 14-164) underwent inguinal EVR via a 3.5-cm inguinal mini-incision. Mean follow up was 10.9 months (range 0.4-69.7). Average grade of reflux was 2.80. Average operative time was 91 minutes (range 51-268). The procedure was successful in 87 of 91 patients (95.6%). The 3 cases of reflux that persisted were all grade 1 and managed expectantly. Contralateral reflux developed in 9 cases, all of which resolved after treatment with either Deflux or ureteral reimplant. There were 4 case of urinary retention that resolved after a brief period of CIC or indwelling catheterization. There were no cases of ureteral obstruction. Most patients were discharged on post-operative day 1 (85/91) and no hospitalization extended beyond 3 days.Conclusions:The inguinal approach to extravesical ureteral reimplantation should be considered as a potentially minimally invasive alternative to endoscopic and robotic treatment of VUR with a success rate more comparable to traditional open approaches. We feel it is the method of choice in cases of unilateral VUR requiring surgical correction.

Laparoscopic vesico-ureteral reimplantation with Lich-Gregoir approach in children: medium term results of 159 renal units in 117 children.

Vesico-ureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. Surgery is an important part of its management. Laparoscopic ureteric reimplantation using the Lich-Gregoir technique is an option for VUR. The aim of this study is to assess short- and medium-term outcomes of this approach. This is a retrospective study including all children with VUR treated by laparoscopic extravesical ureteral reimplantation with the Lich-Gregoir technique in University Hospital of Saint-Etienne from August 2007 to May 2016. Surgery was performed after the age of 12months in cases with repeated urinary tract infection (UTI) and a deterioration of renal function. All patients were followed-up post operatively. 117 children (92 girls, 25 boys) representing 159 renal units were included. The mean age at surgery was 47.1months (±32.7months). The mean follow-up was 59.3months (±31months). The resolution rate for VUR in terms of no febrile urinary UTIs was 98.3%. The mean operative time was 96min (±37.7min) for unilateral procedures and 128min (±46.1min) for bilateral procedures. The mean hospital stay was 25.3h (±6.3h). There was no difference between males and females regarding age, weight, renal function or follow-up duration. Laparoscopic reimplantation with Lich-Gregoir technique is an efficient, quick and safe technique for the management of VUR. The success rate is comparable to open techniques with the advantages of laparoscopic approach; this can potentially be performed as a Day Case procedure.

An Inguinal Approach to Complex Extravesical Ureteral Reimplantation

To report our experience in applying the Lich-Gregoir extravesical ureteral reimplantation (EVR) approach to complex cases (megaureter, duplex systems) through a small inguinal incision, with the goal of minimizing invasiveness. We reviewed the records of all patients who underwent common sheath or tapered EVR through an inguinal incision. Patient characteristics and reflux grade were obtained, and outcomes were assessed. The technique involved a 2-cm incision made in the lowest inguinal skin crease, standard cord exposure and lateral retraction, and opening the floor of the canal to isolate the ureter. Excisional tapering was performed with the ureter dismembered from the bladder and then reimplanted via detrusorrhaphy, whereas common sheath reimplantation was performed with advancement fixation sutures and the ureters in situ. Twenty-eight patients (15 males and 13 females) with a median age of 1.7 years (range: 0.9-4.8 years) were included. Fifteen patients had ureteral tapering, 12 underwent common sheath reimplantation, and 1 child had both. Success was seen in 94% for tapering and 92% for common sheath reimplants, with a mean follow-up of 29.6 months. There were no postoperative obstructions, urinary leaks, or wound infections. The inguinal approach can safely and effectively be applied to cases of extravesical ureteral tapering and common sheath reimplantation.

This Month in Pediatric Urology

No AccessJournal of UrologyThis Month in Pediatric Urology1 Jun 2017This Month in Pediatric Urology Mark P. Cain Mark P. CainMark P. Cain More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.03.095AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "This Month in Pediatric Urology." The Journal of Urology, 197(6), p. 1373 References 1 : A 4-year prospective urological assessment of in utero myelomeningocele repair: does gestational age at birth have a role in later neurogenic bladder pattern?. J Urol2017; 197: 1550. Link, Google Scholar 2 : Multi-institutional review of outcomes and complications of robot-assisted laparoscopic extravesical ureteral reimplantation for treatment of primary vesicoureteral reflux in children. J Urol2017; 197: 1555. Link, Google Scholar © 2017 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 197Issue 6June 2017Page: 1373 Advertisement Copyright & Permissions© 2017 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mark P. Cain More articles by this author Expand All Advertisement PDF downloadLoading ...

Is robot-assisted laparoscopic bilateral extravesical ureteral reimplantation associated with greater morbidity than unilateral surgery? A comparative analysis

Voiding dysfunction after bilateral extravesical ureteral reimplantation for vesicoureteral reflux has long remained a concern. Robotic approach with improved visualization that enables focused and minimal dissection may help with this concern. To compare postoperative outcomes after bilateral robot-assisted laparoscopic ureteral reimplantation to unilateral robot-assisted laparoscopic ureteral reimplantation. This was a retrospective study using data abstracted from an institutional review board-approved registry prospectively maintained at our institution since 2012. Patient demographics, preoperative characteristics, and postoperative outcomes were analyzed. Patients with postoperative febrile urinary tract infection (UTI) underwent voiding cystourethrogram (VCUG). Surgical success is defined as absence of febrile UTI or febrile UTI with negative VCUG. 92 patients with a median follow-up of 14 (25th and 75th IQR 5, 28) months. Median operative time (150 vs. 178min, p=0.01) and median hospital stay (33 vs. 37h, p=0.01) were longer in the bilateral cohort. Weight-adjusted morphine equivalents requirement was also higher in the bilateral group (0.45 vs. 0.59, p=0.019). Early postoperative voiding dysfunction is influenced by anesthesia, postoperative pain, analgesics, age, surgical dissection, and preoperative voiding issues. Effective preoperative management of voiding dysfunction, minimizing surgical dissection and cautery, and minimizing opiate use will aid improving outcomes after surgery and enable bilateral surgeries on uretero-vesical junction. A robotic approach to facilitate such strategies couldhelp outcomes after bilateral ureteral reimplantation. Limitations of this study include its retrospective design, the absence of routinepostoperative VCUG after ureteral reimplantation, and unknown confounding variables. Robot-assisted laparoscopic bilateral extravesical ureteral reimplantation is not associated with an increased risk of postoperative morbidity compared with unilateral surgery.

Multi-Institutional Review of Outcomes and Complications of Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation for Treatment of Primary Vesicoureteral Reflux in Children

Robot-assisted laparoscopic extravesical ureteral reimplantation has been proposed as a minimally invasive alternative to open ureteral reimplantation for correcting primary vesicoureteral reflux in children. However, in the current literature there are conflicting data regarding the safety and efficacy of this approach. Amid ongoing debate we analyzed outcomes and complications from this procedure in a large multi-institutional cohort. We reviewed the records of children who underwent robot-assisted laparoscopic extravesical ureteral reimplantation at 9 academic centers from 2005 to 2014. Radiographic failure was defined as persistent vesicoureteral reflux on postoperative voiding cystourethrogram or radionuclide cystogram. Complications were graded using the Clavien-Dindo scale. A total of 260 patients (363 ureters) underwent robot-assisted laparoscopic extravesical ureteral reimplantation for primary vesicoureteral reflux during the study period. The cohort included 90 patients with either duplex ureter (42), failed endoscopic treatment (40) or concomitant diverticulectomy (8). Of the 280 ureters with postoperative voiding cystourethrogram or radionuclide cystogram available radiographic resolution was seen in 246 (87.9%). There were 25 complications overall (9.6%), with 7 grade 3 complications (2.7%) and no grade 4 or 5 complications. Four patients (3.9%) had transient urinary retention following bilateral reimplantation. Robot-assisted laparoscopic extravesical ureteral reimplantation has a low complication rate consistent with published series of open ureteral reimplantation. Radiographic success rates are approaching those of the open procedure but continue to fall short of the gold standard approach. These findings necessitate critical thinking regarding potential technique improvements and further prospective investigation into the efficacy of this procedure.

Novel technique of laparoscopic extravesical ureteric reimplantation in primary obstructive megaureter

Objective:This study aims to demonstrate a novel laparoscopic technique of tapering megaureter without disrupting the blood supply and disconnecting the ureter.Materials and Methods:Eight cases of primary obstructive megaureter in the age group of 14–22 years underwent laparoscopic extravesical ureteric reimplantation between August 2011 and July 2015 using our novel technique. Five patients had obstruction on left side and three on right side. Follow-up ultrasonography at 1 month and 3 months, voiding cystourethrogram (VCUG) at 3 months and intravenous urogram (IVU) at 6 months was obtained to assess the development of reflux and to look for adequate drainage of the obstructive ureter.Results:Average age of the patients at the time of surgery was 18.5 years. Mean operating time was 95 min. Mean blood loss of 20 ml. VCUG done after 3 months showed no reflux in all cases. IVU done after six months showed no obstruction and complete drainage of dye.Conclusion:Our technique of tapering obstructed megaureter over a preplaced ureteral dilator is time saving and also helps in preserving blood supply to lower ureter. As a result, ureteric anastomotic stricture rate is very low. It is easily reproducible in the open as well as by robotic.

Robot-assisted laparoscopic extravesical ureteral reimplant: A critical look at surgical outcomes

Published reports of outcomes of robot assisted laparoscopic ureteral reimplantation (RALUR) show mixed results that, on average, are inferior to open ureteral reimplant. We present a retrospective analysis of a prospective series of children who had RALUR from 2013 to June 2015. We hypothesized that surgical outcomes are based on identifiable risk variables. We provide a critical analysis of the relationship between patient characteristics and several surgical and non-surgical outcomes. We reviewed the records of children who had Robot-Assisted Laparoscopic (RAL) Ureteral Reimplant (UR) at Nationwide Children's Hospital. Patient age and gender, preoperative presentation, presence of preoperative bladder and bowel dysfunction (BBD), VUR grade and laterality, indication for operation, operative time, surgical outcome, surgical complications, post-operative prevalence of UTI, and pre- and post-operative status of BBD were recorded. We also recorded techniques for ureteral dissection, and closing the detrusorrhaphy. Surgical outcome was defined by post-operative VCUG. We define BBD based on publications by the standardization committee of International Children's Continence Society (ICCS). All statistical calculations were performed with STATA version 11. We performed extravesical RALUR on 54 children for a total of 72 ureters. Overall the study children were 74% female. The mean and median age was 5.2 and 4.9 years, respectively. Mean overall hospital length of stay (LOS) was 1.64 days. The mean LOS was 1.26 for unilateral (RALUUR) and 2.39 days for bilateral (RALBUR) surgeries and was significant (p < 0.05). Overall surgical success was 85.2% of ureters and 84.7% of children. Stratified by unilateral and bilateral surgeries, unilateral success was 91.7%, and bilateral success was 77.8% of ureters, and 72.2% of children. In the 3 failures in the RALUUR group the mean postoperative VUR grade was 1.3 from a pre-op mean grade of 3.3, whereas in the RALBUR group, the mean VUR grade among the failures was 3.0 from a mean pre-op VUR grade of 3.7. Urinary leak from ureteral injury, and urinary obstruction were more common in the RALBUR group. Post-operative urinary retention occurred in 4 children in the RALBUR and none in the RALUUR groups. Four with VUR after RALBUR and one child after RALUUR had open ureteral reimplant. Post-op UTI and non-surgical readmissions were higher in the RALBUR group. Bilateral RALUR is associated with higher failure rates, higher complication rates, higher re-operation rates, and more postoperative UTIs and nonsurgical readmissions compared with unilaterasl RALUR.

Robot-assisted Laparoscopic Extravesical Ureteral Reimplantation: Technique Modifications Contribute to Optimized Outcomes

BackgroundRobot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is being adopted at large pediatric urology centers in the United States, but currently there is not consensus on surgical technique to facilitate the best possible outcomes. ObjectiveTo describe technique modifications that may lead to improved radiographic vesicoureteral reflux (VUR) resolution. Design, setting, and participantsBetween December 2008 and February 2015, a single surgeon performed RALUR-EV at an academic medical center. Only children with persistent grade 3–5 VUR at age 5 yr on voiding cystourethrogram (VCUG), those who had breakthrough urinary tract infections, or those with renal scarring were selected to undergo surgical correction of VUR with RALUR-EV. Children undergoing RALUR-EV for obstructive megaureter or ureterovesical junction obstruction were excluded. Fifty-eight patients (83 ureters) fit the inclusion criteria. Surgical procedureWe highlighted adjustments to our technique, called LUAA to represent length of detrusor tunnel (L), use of a U stitch (U), placement of permanent ureteral alignment suture (A), and inclusion of ureteral adventitia (A) in detrusorraphy. Outcome measurements and statistical analysisThe primary end point was resolution of VUR on postoperative VCUG. Results and limitationsBecause technique modifications were made at two distinct time points, we generated three patient groups for comparison. We observed complete resolution of VUR in 82% of ureters, including 8 of 12 ureters (67%), 8 of 11 ureters (73%), and 52 of 60 ureters (87%) for technique modification cohorts 1, 2, and 3, respectively. There were no ureteral complications at median follow-up of 30 mo. Retrospective design and possible confounding from the learning curve limit this study. ConclusionsUsing the standardized LUAA technique, we demonstrated an improvement in outcomes. Given the wide range of published resolution rates following RALUR-EV, there is a need for standardization of technique to facilitate best possible outcomes. We propose the LUAA technique as a new standard for RALUR-EV to achieve this goal. Patient summaryWe examined the safety and efficacy of a minimally invasive surgery in children. We identified several critical adjustments to surgical technique that improve rates of successful outcome.

Outcomes of complex robot-assisted extravesical ureteral reimplantation in the pediatric population

While open ureteral reimplantation remains the gold standard for surgical treatment of vesicoureteral reflux (VUR), minimally invasive approaches offer potential benefits. This study evaluated the outcomes of children undergoing complex robot-assisted laparoscopic ureteral reimplantation (RALUR) for failed previous anti-reflux surgery, complex anatomy, or ureterovesical junction obstruction (UVJO), and compared them with patients undergoing open extravesical repair. Children undergoing complex RALUR or open extravesical ureteral reimplantation (OUR) were identified. Reimplantation was classified as complex if ureters: 1) had previous anti-reflux surgery, 2) required tapering and/or dismembering, or 3) had associated duplication or diverticulum. Seventeen children underwent complex RALUR during a 24-month period, compared with 41 OUR. The mean follow-up was 16.6±6.5 months. The RALUR children were significantly older (9.3±3.7 years) than the OUR patients (3.1±2.7 years; P<0.001). All RALUR patients were discharged on postoperative day one, while 24.4% of children in the open group required longer hospitalization (mean 1.3±0.7 days; P=0.03). Adjusting for age, there was no significant difference in inpatient analgesic usage between the two cohorts. Three OUR patients (7.3%) developed postoperative febrile urinary tract infection compared with a single child (5.9%) undergoing RALUR (P=1.00). There was no significant difference in complication rate between the two groups (12.2% OUR versus 11.8% RALUR; P=1.00). A postoperative cystogram was performed in the majority of RALUR patients, with no persistent VUR detected, and one child (6.7%) was diagnosed with contralateral reflux. Reported VUR resolution rates following robot-assisted ureteral reimplantation are varied. In the present series, children undergoing RALUR following failed previous anti-reflux surgery, with complex anatomy, or UVJO experienced a shorter length of stay but had similar analgesic requirements to those undergoing open repair. Radiographic, clinical success rates and complication risk were comparable. This study had several limitations, aside from lack of randomization. Analgesic use was limited to an inpatient setting, and pain scores were not assessed. Not all children underwent a postoperative VCUG, so the true radiographic success rate is unknown. A larger patient cohort with longer follow-up is necessary to determine predictors of radiographic and clinical failure. Older children with a previous history of anti-reflux surgery were more likely to undergo RALUR. These children had success and complication rates comparable to younger patients following complex open extravesical reimplantation, which underscores the expanding role of robot-assisted lower urinary tract reconstructive surgery in the pediatric population.

Laparoscopic undiversion of end ureterostomy: A novel technique

We describe a novel technique of laparoscopic undiversion and reimplantation of end ureterostomy in children. Three children (mean age 2.1 y, two girls) underwent laparoscopic undiversion and reimplantation of unilateral end ureterostomy during early infancy for symptomatic primary obstructive megaureter. The procedure consisted of laparoscopic dismantling of stoma, mobilization and medial rerouting of ureter, and extravesical ureteric reimplantation. There were no complications (mean follow-up 10 months). Follow-up investigations revealed only mild residual hydronephrosis with no ipsilateral reflux. Cosmetic results were excellent. Our novel technique allows laparoscopic undiversion of ureterostomy to be performed with success.

Multi-Institutional Review of Outcomes of Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation

We performed a multi-institutional assessment of the outcomes and complications of robot-assisted laparoscopic extravesical ureteral reimplantation for vesicoureteral reflux in children. We retrospectively reviewed the records of patients who underwent robot-assisted laparoscopic extravesical ureteral reimplantation as done by 1 of 5 surgeons at Children's Medical Center, Dallas, Texas, or Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, from 2010 to 2013. Procedure failure was defined as persistent vesicoureteral reflux on postoperative voiding cystourethrogram or radionuclide cystogram and/or the need for reoperation. Multivariate logistic regression was done to identify possible risk factors for failure using STATA®, version 11. A total of 61 patients (93 ureters) with a mean age of 6.7 years (range 0.6to 18.0) underwent a procedure, of which 32 (52%) were bilateral. Ten patients (16%) underwent previous subureteral injection for vesicoureteral reflux. At a mean followup of 11.7 months the procedure was successful in 44 of 61 patients (72%). There were 14 cases of persistent vesicoureteral reflux (23%), 6 complications (10%) and 9 reoperations (11%). Multivariate logistic regression identified no factor that increased the risk of failure (p = 0.737). Compared to the literature we found a notably lower success rate for robot-assisted laparoscopic extravesical ureteral reimplantation in the hands of 5 fellowship trained, robotically experienced pediatric urologists. More than 10% of patients required at least 1 reoperation for persistent vesicoureteral reflux or a surgical complication. Our experience suggests a higher complication rate and a lower success rate for robot-assisted laparoscopic ureteral reimplantation compared to the gold standard of open reimplantation.

Robot-assisted laparoscopic ureteric reimplantation: extravesical technique.

To describe our standardised approach to performing robot-assisted extravesical ureteric reimplantation. A total of 29 children, with high grade (III-V) vesico-ureteric reflux (VUR) underwent robot-assisted extravesical ureteric reimplantation between September 2010 and September 2013. Follow-up renal ultrasonography was performed at 1 month and 3 months and a voiding cysto-urethrogram (VCUG) was obtained at 4 months to assess VUR resolution. The mean (range) patient age at the time of surgery was 5.38 (3.0-10.0) years. Postoperative VCUG showed complete resolution of VUR in 32/40 ureters (80%). Of the remaining refluxing ureters, downgrading of VUR on VCUG was shown in 7/8 ureters (87.5%). The mean (range) length of hospital stay was 1.8 (1-3) days. In conclusion, robot-assisted extravesical ureteric reimplantation is technically feasible with acceptable resolution of VUR.

Carbon dioxide laser for detrusor tunnel creation in robot-assisted laparoscopic extravesical ureteral reimplant

ObjectiveDemonstrate and report initial results using a carbon dioxide (CO2) laser for detrusor tunnel creation in robot-assisted laparoscopic extravesical ureteral reimplant (RALUR). MethodsRetrospective chart review was performed for cases of RALUR from 2011 to 2014. Patients undergoing complex reconstruction (ureteral tailoring, dismembered reimplant, concomitant ureteroureterostomy), and those who had incomplete follow-up were excluded. Variables, including use of the CO2 laser, were collected and correlated with outcomes. Results23 patients representing 40 ureteral units were included for analysis. A CO2 laser was used in 9/23 (39%) patients and 16/40 (40%) ureteral units. Intraoperative mucosotomy was reported in 3/14 (21%) patients for the electrocautery group and 1/9 (11%) patients for the CO2 laser group. Resolution of VUR was observed in 11/14 (79%), and 9/9 (100%) of patients for the electrocautery group and the CO2 laser group, respectively. Two complications were identified in the electrocautery group of patients: ileus (Clavien 2), and transient bilateral ureteral obstruction requiring placement of ureteral stents (Clavien 3B). There were no complications in the CO2 laser group. ConclusionsCreation of the detrusor tunnel with a CO2 laser is safe and effective, and is associated with a lower rate of failure and complication in this cohort.

Extravesical robot-assisted laparoscopic ureteral reimplantation for vesicoureteral reflux: initial experience in Japan with the ureteral advancement technique.

To report our initial experience with robot-assisted laparoscopic extravesical ureteral reimplantation using the ureteral advancement technique. A total of 15 ureters from nine patients (age range 2-25 years) underwent robot-assisted laparoscopic extravesical ureteral reimplantation for the management of vesicoureteral reflux. The reflux was classified as grade I in one ureter, grade II in two ureters, grade III in seven ureters, grade IV in three ureters and grade V in two ureters. One of the five female patients had a bilateral duplex system, and reflux was observed in all four ureters. The da Vinci surgical system was utilized. Ureteral advancement was carried out in all cases. We also compared the operative outcomes between conventional laparoscopic procedure and robotic surgery. The console time was 211.5 ± 87.4 min (median ± standard deviation) in the bilateral cases and 144.0 ± 40.8 min in the unilateral cases. Urethral catheters were removed at one or two postoperative days. None of the patients suffered postoperative complications, such as urine leakage or urinary retention. Postoperative voiding cystourethrography showed that the reflux had been resolved in 14 of the 15 ureters (success rate 93.3%). In the remaining case, the reflux grade decreased from III to I. The operative outcomes of robotic surgery were favorable and safe compared with conventional laparoscopic procedure. Our preliminary results showed that robot-assisted laparoscopic surgery is a feasible and useful approach to extravesical ureteral reimplantation, even for patients with bilateral reflux.

Patient Positioning and Port Placement for Robot-Assisted Surgery

Abstract The introduction of robotic surgical systems and their integration into minimally invasive procedures have changed the landscape of laparoscopic surgery dramatically. Intuitive Surgical's da Vinci Surgical System was first approved by the Food and Drug Administration for cardiothoracic procedures in the late 1990s. This trend quickly spread through other surgical specialties, with urologists as one of the frontrunners in adoption. Subsequently, pediatric urologists have adopted robot-assisted procedures in selected centers, performing procedures such as pyeloplasty for ureteropelvic junction obstruction, partial and complete nephrectomy, and both intravesical and extravesical ureteral reimplantation. In this article, we will discuss technical considerations related to patient positioning and port placement in pediatric robot-assisted surgery.