Lich-Gregoir Technique Research Articles

Abdominal hysterectomy due to uterine rupture causing bilateral ureterovaginal fistula: A rare case report

Abstract Ureterovaginal fistula (UVF) is defined as abnormal communication between ureter and vagina. Although documented after radical hysterectomy, post radiation and retained pessary incidence of bilateral UVF is still very rare. We have documented a case report of a multipara woman presented with persistent urinary leakage following an emergency hysterectomy for obstructed labor. After evaluation with imaging there was bilateral hydroureterophrosis with dense purulent collection mixed with contrast in the vesicular area with lower end of ureter draining in the vaginal vault with preserved renal function. During exploration both ureters were dilated. Instillation dye in both ureters showed extravasation in vagina. After ligating distal ends modified Lich-Gregoir technique done over double J (DJ) stents. DJ removed after 3 months. Bilateral UVF is only 5%–10% of all ureteric injury. Aggressive blind clamping, excessive hemorrhage, distorted anatomy, malignancy and surgeons experience play a crucial role. Obstetric cause is the prime factor. Preventing measures like proper screening of antenatal patients, early detection of high-risk pregnancy, supervised caesarean section should be taken to avoid ureteric injuries

Sequence of Surgical Approach in a Patient with Autosomal Dominant Polycystic Kidney Disease Treated with Renal Transplantation

Introduction: Describe the surgical sequence in a 55-year-old woman with an Autosomal Dominant Polycystic Kidney (ADPKD) Case Presentation: We performed three surgical procedures in a woman with Chronic Kidney Disease (CKD) secondary to ADPKD of 13 years of evolution from June to November 2023 which are as follows: Resection of 2 liver cysts and Laparoscopic cholecystectomy, Related living donor renal transplant, and Bilateral open nephrectomy, all of them with the use of innovative technology. Result: The first procedure was performed for risk reduction and two cysts of 3.5 cm x 1.6 cm x 1.5 cm and 3.3 cm x 2.0 cm x 1.4 cm and chronic cholecystitis were reported. The second one was performed one month later; the patient had previous creatinine values of 4.73. The graft was positioned in the right iliac fossa where end-to-side anastomosis of renal vessels was performed with external iliac vessels and uretero-vesical anastomosis was executed with the Lich-Gregoir technique; the total ischemia time was 109 minutes and the kidney presented immediate function. At 48 hours, a Doppler ultrasound was performed, which reported a renal artery resistance index of 0.5, with homogeneous cortical perfusion, without collections, vessels, and ureter without stenosis or thrombosis; therefore, the patient was discharged 5 days after the transplant with optimal graft function and creatinine levels of 1.75. In the last procedure, two kidneys of 1.6 kg each were obtained and pathology reported adult polycystic disease with interstitial fibrosis, chronic inflammation, dystrophic calcification, tubular and glomerular atrophy. At the moment she has stable graft function and went from having creatinine levels of 4.73 to 1.2 and her glomerular filtration rate went from 9.68 to 50.84.

Full-thickness Ureteroneocystostomy in Kidney Transplant: Evaluation of Complications and Graft Survival Outcomes at a High-volume Center

Objectives: To report a large series where the full-thickness (FT) technique was applied and evaluate infectious and functional outcomes and compare these to the available literature. The ureteroneocystostomy technique of kidney transplantation has great variability. Kidney transplants performed at our institution use the FT technique as opposed to most centers. Ureteroneocystostomy performed without an anti-reflux mechanism (without tunneling) may increase the risk of acute renal graft pyelonephritis (AGPN) and thus compromise graft survival. Methods: Retrospective cohort study, based on 1275 medical records of kidney transplanted patients between 2007 and 2018. The outcomes were renal graft survival, ureteral complications, and occurrence of AGPN. Kaplan-Meier’s analysis is used to describe estimated time averages and variability through the Log-Rank test. Poisson regression model is used to estimate multivariable prevalence ratios. Results: We found that renal graft survival rates were comparable to those found in the literature. The AGPN rate in our series was 12.53 episodes/100 patient-years, like other series in the literature. The ureteral complications rates are also similar. Our limitations were the impossibility to compare our results with a controlled group and the limited data underlying pathologies, rejection, and type of immunosuppression. Conclusions: The FT technique has survival outcomes and complications comparable to those of the Lich-Gregoir (LG) technique. The FT technique is simple and quicker to perform than LG and is a suitable alternative for ureteroneocystostomy for kidney transplant procedure.

Improving Surgical Safety in Living Donor Renal Transplantation With Antiseptic Skin Preparation, Bladder Irrigation, Corner-Saving Vascular Anastomosis, DJ Stenting, and Extravesical Ureteroneocystostomy Modifications: A Comprehensive Approach.

Introduction The antiseptic skin preparation, bladder irrigation, corner-saving vascular anastomosis, DJ stenting, and extravesical ureteroneocystostomy (ABCDE) approach encompasses a range of modifications applied during different stages of the surgical procedure in renal transplantation. These modifications include the following: A, antiseptic skin preparation sequentially with cetrimide 3.35%, chlorhexidine scrub 4%, spirit, and povidone-iodine 10%; B, bladder irrigation with amikacin and betadine solution;C, corner-saving end-to-side vascular anastomosis; D, DJ stenting with early postoperative removal within three weeks; and E, extravesical ureteroneocystostomy using our institute's modified Lich-Gregoir technique. Methods This prospective observational study was conducted at our institution between March 2021 and May 2023. Data were collected from the patients' medical records and analyzed using Statistical Package for the Social Sciences (SPSS) (IBM SPSS Statistics, Armonk, NY, USA). Statistical tests, including t-test, Mann-Whitney test, chi-square test, and Fisher's exact test, were used for analysis. The study assessed various recipient, donor, intraoperative, and post-transplant factors, as well as surgical complications and stent-related factors. Results Out of 72 renal transplantations, 12 (16.6%) had the followingsurgical complications: urinary(n= 4; 5.5%), wound-related (n= 3; 4.1%), andlymphocele(n= 5; 6.9%). The most common complications werelymphocele(n= 5; 6.9%) and urinary leak (n= 4; 5.5%). Surgical complications were more common in male recipients (91.6% versus 8.3%), as well as in recipients with longer dialysis duration (24 ± 17 versus 11.0 ± 7 months) and had extended hospitalization time (16.4 ± 8.6 versus 8.0 ± 2.9 days) (p < 0.05). Wound infectioncorrelated with longer surgeries (>300 minutes) and other complications. Lymphocele patients had higher drain output (>500 mL) on day 1 and longer hospital stays (>15 days). Urinary tract infections (UTIs) were linked to dialysis duration (>24 months), diabetes, and longer indwelling times of DJ stents and urinary catheters. Early DJ stent removal (<3 weeks) reduced UTI incidence and symptoms (p < 0.05). All complications were categorized as minor (3a or less), according to the Clavien-Dindo classification. Conclusion The modified ABCDE surgical approachin renal transplantation decreased the complications, showing favorable outcomes compared to those in the literature.

Kidney Transplantation in Nigeria: A Single Centre’s Early Surgical Experience and Outcomes

With the rise in the population of patients with End-stage Renal Disease (ESRD) in Nigeria, there is an increased demand for Renal Replacement Therapy (RRT) including kidney transplantation (KT). We present our initial surgical experience and early outcomes with KT at a Nigerian transplant center over 2 years. A 2-year retrospective review of patients who underwent KT was done. Data of both kidney donors and recipients were recorded in designed proformas. Extracted information included demographic characteristics, side of open donor nephrectomy (ODN), recipient anatomy, surgical techniques and postoperative outcomes. Data were analyzed using SPSS version 21. A total of 210 patients had KT during the period under review&lt;em&gt;. &lt;/em&gt;Donors had an age range of 19 to 53 years with a mean of 30.8 3 ± 8.43 years while recipients aged between 9 and 73 years with a mean of 45.97 ± 13.71 years. There were 190 (90.5%) male and 20 (9.5%) female donors. One hundred fifty-four recipients were males (73.3%) and 56 (26.7%) were females. Left ODN was performed in 152 (72.4%) of cases and the commonest indication for right ODN was multiple left renal arteries. The allograft was placed in the right iliac fossa in 187 (89.0%) recipients with the external iliac artery preferred for anastomosis with the allograft renal artery in end-to-side fashion in 182 (86.7%) cases. The internal iliac artery was used in end-to-end fashion anastomosis in 28 (13.3%) of cases. Ureteroneocystostomy using the Modified Lich-Gregoir technique over a double-J stent was performed in all but 5 patients who had uretero-ureterostomies. Significant peri-operative hemorrhage necessitating blood transfusion was experienced in 9 donors and 26 recipients. There was a low complication rate in kidney donors. Allograft renal artery thrombosis, venous thrombosis, and arterial pseudo-aneurysms were encountered in 3, 2 and 4 recipients respectively. Kidney transplantation can be safely and routinely carried out in Nigeria. The early surgical outlook of both kidney donors and recipients was found to be excellent in this study.

Robotic-assisted surgery in pediatrics: what is evidence-based?-a literature review.

The use of robotic-assisted surgery (RAS) has increased more slowly in pediatrics than in the adult population. Despite the many advantages of robotic instruments, the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) still presents some limitations for use in pediatric surgery. This study aims to examine evidence-based indications for RAS in the different fields of pediatric surgery according to the published literature. A database search (MEDLINE, Scopus, Web of Science) was performed to identify articles covering any aspect of RAS in the pediatric population. Using Boolean operators AND/OR, all possible combinations of the following search terms were used: robotic surgery, pediatrics, neonatal surgery, thoracic surgery, abdominal surgery, urologic surgery, hepatobiliary surgery, and surgical oncology. The selection criteria were limited to the English language, pediatric patients (under 18 years of age), and articles published after 2010. A total of 239 abstracts were reviewed. Of these, 10 published articles met the purposes of our study with the highest level of evidence and therefore were analyzed. Notably, most of the articles included in this review reported evidence-based indications in urological surgery. According to this study, the exclusive indications for RAS in the pediatric population are pyeloplasty for ureteropelvic junction obstruction in older children and ureteral reimplantation according to the Lich-Gregoire technique in selected cases for the need to access the pelvis with a narrow anatomical and working space. All other indications for RAS in pediatric surgery are still under discussion to date, and cannot be supported by papers with a high level of evidence. However, RAS is certainly a promising technology. Further evidence is strongly encouraged in the future.

Comparison of split-cuff nipple and modified Lich-Gregoir ureteroneocystostomy in iatrogenic distal ureteral injuries: tertiary care center experience.

In this study, we aimed to compare the results of split-cuff nipple and modified Lich-Gregoir ureteroneocystostomy, which are the most commonly used techniques in stage ≥ 3 iatrogenic distal ureteral injuries. The files of patients who were treated for iatrogenic distal ureteral injuries in our clinic between January 2013 and January 2019 were retrospectively reviewed. A total of 60 patients who underwent either intra-vesical split-cuff nipple ureteroneocystostomy (Group A) or extra-vesical modified Lich-Gregoir ureteroneocystostomy (Group B) operations were included in the study. The success of ureteroneocystostomy was defined as no additional surgery requirement, no progression of hydronephrosis on imaging, and normal contrast transition on imaging. Thirty-four patients underwent split-cuff nipple and 26 patients underwent modified Lich-Gregoir ureteroneocystostomy. The treatment was successful in 53 (88.3%) patients and failed in seven (11.7%). Complications occurred in 19 (31.7%) patients, of whom 14 (23.3%) had minor and five (8.3%) had major complications. The rate of postoperative complications was significantly higher in Group A than in Group B (p = 0.019). There was no significant difference between Group A and Group B in terms of the success ratio (p = 1), rate of major complications (p = 0.372), and postoperative hospitalization times (p = 0.254). In this study, a higher complication rate was found in patients with iatrogenic ureteral injuries who underwent ureteroneocystostomy with the split-cuff ureteral nipple technique compared to those who underwent this operation with the modified Lich-Gregoir technique. However, no significant difference was observed between these two techniques in terms of treatment success and major complications.

Laparoscopic vs Open Extravesical Ureteral Reimplantation in Pediatric Population: A Single-Center Experience.

To evaluate the safety and efficacy of conventional laparoscopic vs open Lich-Gregoir ureteral reimplantation in pediatric vesicoureteral reflux. A retrospective study was conducted in a tertiary care hospital. Patients with vesicoureteral reflux who underwent open or laparoscopic Lich-Gregoir ureteral reimplantation from 2013-2020 were included. The primary outcome was resolution of reflux. Complications and perioperative characteristics were evaluated. The outcomes between open and laparoscopic surgery were analyzed. A total of 110 patients and 150 ureters were included. The mean age was 4.5 years ± 3.4 and 73.6% were females. A total of 125 ureters (83.3%) underwent laparoscopic and 25 (16.6%) open Lich-Gregoir vesicoureteral reimplantation (5:1 Ratio). Resolution was reported in 112 (89.6%) for laparoscopy and 21 (84%) for open surgery (P = .42). Mean surgical time for laparoscopy and open surgery were 142.4 min ± 64.4 and 153 min ± 40, respectively (P =.29). Mean bleeding (9.5 mL ± 11.2 vs 29.6 mL ± 22.8) and length of hospital stay (2.4 days ± 2.3 vs 5.05 ± 3.1) were significantly higher with open surgery (P < .001). No significant difference in complications was reported between open surgery (32%) and laparoscopic approach (22.4%) (P = .305). Conventional laparoscopic vesicoureteral reimplantation with the Lich-Gregoir technique has an acceptable success rate comparable with open surgery, with shorter hospital stay, less bleeding, and less need of transfusion.

Observational Study of Early Outcomes in Single-Vessel and Multiple-Vessel Renal Allograft.

IntroductionEnd-stage renal disease (ESRD) is a global problem with a similar worldwide need for renal replacement therapy. However, the availability of transplant organs remains a challenge. Therefore, we conducted this study to measure early outcomes (up to one month) of renal allograft functions after renal transplant by assessing graft vascularity. We also measured the changes in serum creatinine and hemoglobin levels in single- and multiple-vessel renal allograft recipients.MethodsWe conducted an observational study of 108 renal allograft patients for two years. The study included all renal allograft recipients during the study period. The study excluded patients with a history of renal transplant, patients on antithrombotic therapy, a donor with previous surgery of graft kidney, and patients with anatomic abnormalities. Eighty-five patients were in the single-vessel group, and 23 were in the multiple-vessel group. Donors and recipients received standard pretransplant workup, including donor CT angiography and human leukocyte antigen crossmatching. We performed laparoscopic donor nephrectomies for all participants and perfused all renal arteries separately with Renograph solution (Claris Lifesciences, North Brunswick, NJ). A renal transplant was done in the right or left iliac fossa, noting warm and cold ischemia times. In single-vessel recipients, we anastomosed the renal artery to the external iliac artery (EIA), the renal vein to the external iliac vein (EIV), and the ureter to the bladder via a modified Lich-Gregoir technique. In multiple-vessel recipients, we performed bench anastomosis to make a single vessel, or we anastomosed vessels separately to the EIA, EIV, or the inferior epigastric artery for patients with a second small renal artery. We measured postoperative serum creatinine and hemoglobin levels for one month. In addition, we assessed graft vascularity with ultrasound-guided (USG) Doppler in the first postoperative week. We used IBM SPSS Statistics for Windows, version 21.0. (IBM Corp., Armonk, NY) for all data analyses.ResultsWarm ischemia time (WIT) was longer in multiple-vessel patients than in single-vessel patients, but the difference was insignificant (p=0.054). Cold ischemia time (CIT) was significantly longer in the multiple-vessel group than in the single-vessel group (p=0.048). We found no significant difference in serum creatinine or hemoglobin levels between groups during the study period. Perigraft collection occurred in three single-vessel patients and decreased vascularity in two multiple-vessel patients, according to USG Doppler.ConclusionsWe conducted this study to measure early outcomes of renal allograft functions after renal transplant by assessing graft vascularity, serum creatinine, and hemoglobin levels in single- and multiple-vessel renal allograft patients. According to our results, renal transplantation is not inferior in multiple-vessel allograft patients. We found no significant difference in serum creatinine levels one month postoperatively. Using multiple-vessel donors helps increase the limited donor pool, which is ultimately better for managing ESRD patients.

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.

A Stentless Modified Lich-Gregoir Technique for Safe Early Bladder Catheter Removal in Living and Deceased Kidney Transplants

To describe a stentless modified Lich-Gregoir technique (mLG) for ureteroneocystostomy in renal transplantation (RT), with early bladder catheter (BC) removal (under 48 hours), and compare the postoperative results with those of the traditional technique (LG) with routine bladder catheter removal (4 to 5 days). The modification consists of maintaining a thin layer of detrusor fibers covering the bladder mucosa during dissection, which is incorporated into the anastomosis to reinforce the ureteroneocystostomy. This retrospective cohort study compared the postoperative outcomes of 100 consecutive patients who underwent mLG with early removal of BC between October 2018 to November 2019 with those of a historical cohort of 165 consecutive patients transplanted using stentless LG and routine removal of BC, who underwent surgery between July 2017 and September 2018. All transplants were performed by the same surgeon. Follow-up was 6 months. Demographic characteristics were comparable, although patients in the mLG group had a higher mean preoperative urine volume (911 ± 753.8mL vs 629 ± 638.6mL, P =.016). Patients in the mLG group successfully underwent early BC removal (2.2 ± 0.9 vs 4.8 ± 4.8 days, P <.001), with no differences in the incidence of surgical or clinical complications, including urine leaks (1% vs 3%, P =.284). In addition, mLG patients presented a shorter mean length of hospital stay (6.5 ± 5.0 vs 7.1 ± 6.2 days, P =.023). This stentless modified Lich-Gregoir technique enables safe early bladder catheter removal and is associated with reduced hospital length of stay.

Böbrek Nakli Sonrası Ürolojik Komplikasyonların Yönetimi: Deneyimlerimiz ve Teknik Alternatifler: Retrospektif Klinik Araştırma

Objective: Renal transplantation is the primary treatment method for end-stage kidney disease. Many reasons such as surgical reasons and infection may cause urological complications after transplantation. Management of renal transplantation urinary complications requires respectable surgical experience. In this study, we aimed to present the management of patients who require surgical reconstruction after renal transplantation at our center. Material and Methods: The data of 16 patients who underwent reconstructive surgery after transplantation were reviewed retrospectively. The patients' demographic data were evaluated. Which reconstructive method was applied to the patients, timing of surgical correction after transplantation, pre and post-surgical glomerular filtration rate (GFR) were evaluated. Result: Them mean age of the patients was 35.6 years. The mean time from transplantation to reconstructive surgery was 312 days. The average postoperative hospitalization time was 11.2 days. The earliest complication was total ureteral necrosis seen on the 21st postoperative day and the latest complication was vesicoureteral reflux (VUR) in our series. In patients who developed VUR, VUR was seen more than 6 months after the operation. Nephrostomy was placed in 75% of patients. Ureteroneocystostomy was applied to 3 patients (18.7%), one was applied with Boari flap, and two were applied with modified Lich-Gregoir technique. Pre-operative GFR inter-quantile range (IQR): 35.6-70.3, postoperative first-month GFR IQR: 47.4-69.5, third postoperative months GFR IQR: 50-74.5 were detected. A significant difference was observed between preoperative GFR and postoperative third month GFR (p=0.007). Conclusion: Reconstructive surgery following kidney transplantation is a challenging but effective method. Even if it is performed in different centers, complications after transplantation are likely to occur.

Indications for operation and results from surgical treatment of vesicoureteral reflux

The main objective of this retrospective study was to evaluate the value of surgical approach in the treatment of children with vesicoureteral reflux (VUR). Material and method: The study was conducted in the period from January 2006 to December 2014, and included children with symptomatic VUR, who were surgically treated. A total of 72 children were treated, of whom 56 were females and 16 were males, aged between 2 and 16 years. They were treated with IV and V grade reflux ureters. Thirty-two of the unilateral refluxes were left-sided, 18 right-sided and 22 both-sided. VUR was diagnosed with Voiding cystourethrography (VCUG). Cohen technique was performed in 64 (90%) patients, Politano-Lead better technique in 4 (5%) patients and Lich-Gregoir technique in 4 (5%) patients. Results: Out of the 72 treated patients, 69 had a postoperative negative finding of VUR on the performed VCUG, indicating a high 95% success rate. In three girls, persistent postoperative reflux was found in postoperative VCUG. In the first patient persistent VUR was unilateral, of V grade. In the second patient, a third-degree VUR was found and the third patient was diagnosed with II grade VUR. Postoperatively, non-febrile UTIs (urinary tract infections) were diagnosed in 23 patients (20 female children and 3 male children) out of 72 patients in total. One female child was hospitalized with febrile UTI and 8 patients or 10% developed febrile UTI within one year of the operative treatment. Conclusion: Open surgery, despite excellent results, is used for more complicated cases, VUR grade IV – V or in previously failed cases, and it does not appear to provide definitive correction of VUR in all patients and does not prevent certain low incidence of UTI postoperatively. Non-febrile UTIs can occur several years after a surgical correction. Endoscopic treatment is an alternative treatment for VUR

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 ureteral reimplantation applying the modified psoas hitch and Lich-Gregoir onlay technique: a 10-step surgical video.

Describe the surgical technique of laparoscopic ureterovesical reimplantation applying the modified psoas hitch with Lich-Gregoire onlay technique to manage a distal ureteral fistula after a hysterectomy for a gynecologic malignancy. This video illustrates the surgical technique of laparoscopic ureteral reimplantation applying the modified psoas hitch with Lich-Gregoire onlay technique in a ten-step surgical video. Step 1: closure of the caudal ureter.Step 2: Ureter mobilization. Step 3: Ureter spatulation. Step 4: Bladder mobilization. Step 5: Detrusor muscle incision. Step 6: Bladder suspension. Step 7: Mucosal incision. Step 8: Ureterovesical anastomosis. Step 9: JJ stent insertion. Step 10: Detrusor muscle closure. Intraoperative identification of ureteral injury and prompt repair are recommended. Ureteral repair technique depends on the ureteral injury site. Distal ureteral injuries (UIs) might require either uretero-ureterostomy or ureteral reimplant with or without a psoas hitch. The Lich-Gregoir is one of the two most frequently used anti-vesicoureteral reflux techniques and has acceptable complication rates.

Robot-assisted Kidney Transplantation.

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed in the supine Trendelenburg position. Kidney allografts are provided by a living donor. Before vascular anastomosis, the kidney allograft is prepared by inserting a double-J stent in the ureter, and the temperature for the anastomosis is lowered by wrapping it in an ice-packed gauze. A 12 mm or 8 mm port for the robotic camera and three 8 mm ports for robotic arms are placed. A peritoneal pouch is created for the kidney allograft by raising the peritoneal flaps on both sides over the psoas muscle before dissecting the iliac vessels and bladder. A 6 cm Pfannenstiel incision is made to insert the kidney into the peritoneal pouch, lateral to the right iliac vessels. After clamping the external iliac vein with Bulldogs clamps, a venotomy is performed, and the graft renal vein is anastomosed to the external iliac vein in an end-to-side continuous manner with a 6/0 polytetrafluoroethylene suture. After clamping the graft renal vein, the iliac vein is declamped. This is followed by clamping of the external iliac artery, arteriotomy, arterial anastomosis with a 6/0 polytetrafluoroethylene suture, clamping of the graft renal artery, and declamping of the external iliac artery. Reperfusion is then carried out, and ureteroneocystostomy is performed using the Lich-Gregoir technique. The peritoneum is closed at a few locations with polymer locking clips, and a closed-suction drain is placed through one of the working ports. After deflating the pneumoperitoneum, all incisions are closed.

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.

Utilization of Robot-assisted Surgery for the Treatment of Primary Obstructed Megaureters in Children

To describe the technical aspects of robot assisted laparoscopic ureteral reimplantation (RALUR) for the management of primary obstructive megaureter (POM) and report initial outcomes, safety, and feasibility of the procedure. Using an IRB- approved robotic surgery registry, we performed a retrospective chart review of patients undergoing RALUR for POM between April 2009 and May 2019. A total of 18 patients underwent RALUR using a modified Lich-Gregoir technique for management of POM and 7 (38.9%) of these underwent intracorporeal ureteral tapering at the time of surgery. At median follow up of 27.5 (IQR 11-50) months, no patient required reoperation for recurrent obstruction and all patients had improvement in hydronephrosis postoperatively. 30-day complications were low with 1 Grade I, 2 Grade II and 1 Grade III Clavien-Dindo complication. The most common issue postoperatively was febrile urinary tract infection, occurring in 6 patients (33.3%), at an average of 3.2 months after surgery. Increased operative time was the only significant difference between the tapered verses nontapered group. We present the largest series of RALUR for POM to date. Based upon our initial experience with this technique we believe it is technically feasible and reproducible with good outcomes and low complication rates. Future studies are needed to track long-term outcomes and better understand indications for and the utility of ureteral tapering as well as how to minimize febrile UTIs postoperatively. Additional follow up is needed to determine the efficacy of RALUR as compared to open ureteral reimplantation for POM.

Comparison of Ureterovesical Reimplantation Lich-Gregoir and De La Cruz-Jean Modified Techniques in Urologic Complications Post Pediatric Renal Transplantation

Limited data suggests that morbid obesity (Body Mass Index- BMI > 35 kg/m2) increases complications after left ventricular assist device (LVAD) implantation and after heart transplantation (HTx). We comprehensively compared LVAD and heart transplantation (HTx) outcomes in patients with and without morbid obesity.