Robot-assisted Laparoscopic Ureteral Reimplantation Research Articles

Commentary to a multi-institutional European comparative study of open versus robotic-assisted laparoscopic ureteral reimplantation in children with high grade (IV–V) vesicoureteral reflux

Commentary to a multi-institutional European comparative study of open versus robotic-assisted laparoscopic ureteral reimplantation in children with high grade (IV–V) vesicoureteral reflux

A multi-institutional European comparative study of open versus robotic-assisted laparoscopic ureteral reimplantation in children with high grade (IV–V) vesicoureteral reflux

Traditionally, open ureteral reimplantation (OUR) has been the standard treatment for primary vesicoureteral reflux (VUR) requiring reimplantation. Robotic-assisted laparoscopic ureteral reimplantation (RALUR) is gaining popularity and high success rates have been reported. In this multi-institutional study, we aimed to compare the perioperative and postoperative outcomes of OUR and RALUR for high-grade (IV+V) VUR in children. A retrospective evaluation was performed collecting data from 135 children (0-18 years) who underwent high grade VUR surgical correction at nine European institutions between 01/01/2009 and 01/12/2020, involving either open or robotic approaches. Institutional review board approval was obtained. Patients with lower grades of VUR (≤III), previous history of open or endoscopic ureteral surgery, neurogenic bladder, or refluxing megaureter in need of ureteral tapering were excluded. Pre-, peri- and post-operative data were statistically compared. Overall, 135 children who underwent either OUR (n=68), or RALUR (n=67) were included, and their clinic and demographic features were collected. The mean age of the open group was 11 months (interquartile range [IQR] 9.9-16.6 months), in the RALUR group it was 59 months (IQR 29-78mo) (p<0.01); the open cohort had a weight of 11kg (IQR 9.9-16.6kg) while the RALUR group had 19kg (IQR 13-25kg) (p<0.01). No significant differences were found for intraoperative (1.5% vs 7.5%, p=0.09) or for postoperative complication rates (7.4% vs 9%, p=0.15). Favorable outcomes were reported in the RALUR group: shorter time to stooling (1 vs 2 days), fewer indwelling urethral catheter days (1 vs 5 days), perioperative drain insertion time (1 vs 5 days) and a shorter length of hospital stay (2 vs 5 days) (p<0.01). The success rate was 94.0% and 98.5% in the open and RALUR groups, respectively. The long-term clinical success rates from both groups was comparable:42 vs 23 months for open and RALUR, respectively. This study reported a large multicentric experience focusing on high grade VUR. Furthermore, this study compares favorably to OUR in a safety analysis. There was also a trend towards higher success rates with RALUR utilizing an extravesical approach which has not been previously reported. RALUR is an efficacious and safe platform to use during ureteral reimplantation for high grade VUR. The overall peri-operative and post-operative complication rates are at least equivalent to OUR, but it is associated with a faster functional recovery and time to discharge. Medium to long term success rates are also equivalent to OUR.

Does previous endoscopic subureteric injection (STING) effect the outcomes of robot-assisted laparoscopic ureteral reimplantation surgery (RALUR) in children?

There is lack of evidence on the success of robot-assisted laparoscopic ureteral reimplantation (RALUR) for the treatment of vesicoureteral reflux (VUR) who had prior intervention. This study aimed to evaluate the effect of previous unsuccessful STING on the outcomes of RALUR in children. A total of 67 children treated with RALUR by a single surgeon for the treatment of VUR were scanned between February 2018 and April 2022. Two patients were excluded from the final data analysis due to the presence of a megaureter. Patients were divided into two groups: those with a history of STING (Group A - n:14) and those without STING (Group B - n:51). Patient characteristics, previous numbers of injections, console time, total operative time, perioperative and postoperative complications and clinical success data were collected. Clavien Dindo and Satava complication scales were used as the standard record of peri and postoperative complications. Radiographic success was defined as absence of reflux detected on postoperative voiding cystourethrography, whereas clinical success was defined as the absence of a febrile urinary tract infection during the follow-up. Mann-Whitney U and Chi-square tests and Fisher exact test were used where appropriate. A total of 36 (55.3%) female versus 29 (44.6%) male patients were operated for 96 refluxive ureters. Nearly half of the patients were with bilateral VUR (n=31). The mean follow-up was 20.2±15.4 months. The median age of patients was 59±31 (range: 28-132 months) versus 46±33.1 (range: 7-206 months) for groups A and B respectively (p=0.22). Gender, age, peri- and postoperative complication rates, and clinical success were comparable between the two groups. The median operative time and the console time was significantly higher in children with history of STING (op time: 142.5±27.4 versus 120±24.9min (p=0.008), console time: 117.5±28.2 versus 100±24.5min (p=0.011) for groups A and B, respectively. A total of six complications (9.2%) occurred with none of them were greater than Clavien grade 3b. The overall clinical success rate was 97%, with 2 cases of clinical failure. In both cases, VCUG demonstrated absence of VUR. The outcomes of our study provided that RALUR is effective with more than 95% success rates despite failed endoscopic injection procedures. The previous history of STING neither changes the success nor the complication rates of RALUR. However, this can lead to more challenging surgery by increasing the total operative times.

Tips and tricks for the extravesical robotic-assisted laparoscopic ureteral reimplantation for pediatric vesicoureteral reflux

Over the past few years, robotic-assisted laparoscopic ureteral reimplantation (RALUR) has gained popularity as an acceptable alternative for the traditional open approach if surgery is elected for children with vesicoureteral reflux (VUR). We present our technique including the tips and tricks for both male and female patients, including a stepwise approach for ureteral identification in female patients depending on the level of technical difficulty. Our series include 30 patients who represent a spectrum in which we presented the different tips and tricks included in this video.

MP70-08 OUTCOMES AND SAFETY OF ROBOTIC-ASSISTED LAPAROSCOPIC URETERAL REIMPLANTATION IN INFANTS LESS THAN 24 MONTHS OF AGE WITH PRIMARY VESICOURETERAL REFLUX

You have accessJournal of UrologyCME1 Apr 2023MP70-08 OUTCOMES AND SAFETY OF ROBOTIC-ASSISTED LAPAROSCOPIC URETERAL REIMPLANTATION IN INFANTS LESS THAN 24 MONTHS OF AGE WITH PRIMARY VESICOURETERAL REFLUX Sahar Eftekharzadeh, Katherine Fischer, Aznive Aghababian, Sameer Mittal, John Weaver, Karl Godlewski, Christopher Long, Dana Weiss, Aseem Shukla, and Arun Srinivasan Sahar EftekharzadehSahar Eftekharzadeh More articles by this author , Katherine FischerKatherine Fischer More articles by this author , Aznive AghababianAznive Aghababian More articles by this author , Sameer MittalSameer Mittal More articles by this author , John WeaverJohn Weaver More articles by this author , Karl GodlewskiKarl Godlewski More articles by this author , Christopher LongChristopher Long More articles by this author , Dana WeissDana Weiss More articles by this author , Aseem ShuklaAseem Shukla More articles by this author , and Arun SrinivasanArun Srinivasan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003338.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While the use of robotic assisted laparoscopic ureteral reimplantation (RALUR) for management of vesicoureteral reflux (VUR) in the pediatric population has been well reported over the years, the use of RALUR in the infant cohort (<24 months of age) remains lower than older children likely due to perceived technical challenges including robotic arm collision in a small working space. We hypothesize that the safety and efficacy of performing RALUR on patients <24 months of age is comparable to an older cohort. METHODS: An IRB approved single-institutional registry was queried to retrospectively identify all patients under 18 years of age who underwent RALUR for primary VUR between 2012 - 2019. Patients undergoing concomitant procedures or with duplex renal collecting systems were excluded. We categorized patients into two groups: 1) <24 months of age 2). >24 months of age. Demographics, pre-operative imaging, operative details, and post-operative outcomes including 30-day complications, persistent VUR, incidence of febrile UTI (fUTI), dysfunctional voiding, and rate of reintervention was aggregated. RESULTS: Of 172 patients who underwent RALUR during the study period, 141 (82%) met inclusion criteria: 29 in the <24 months group, and 112 in the >24 months group (Table 1). There was a higher incidence of breakthrough UTIs in the <24 months group (p<0.001), occurring in 28/29 patients (97%) in this group. Patients <24 months old had a higher percentage of fUTIs within 30 days of surgery (Clavien-Dindo Grade II). There was no statistical difference in the length of surgery, use of straight catheterization, persistent VUR, dysfunctional voiding, fUTIs occurring >30 days after surgery, or need for further interventions between the two groups (Table 2). 7 patients from both groups required subsequent intervention. CONCLUSIONS: Outcomes of patients undergoing RALUR for primary VUR are favorable regardless of age. RALUR is technically feasible, safe, and efficacious for management of primary VUR in patients younger than 24 months. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1006 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sahar Eftekharzadeh More articles by this author Katherine Fischer More articles by this author Aznive Aghababian More articles by this author Sameer Mittal More articles by this author John Weaver More articles by this author Karl Godlewski More articles by this author Christopher Long More articles by this author Dana Weiss More articles by this author Aseem Shukla More articles by this author Arun Srinivasan More articles by this author Expand All Advertisement PDF downloadLoading ...

V04-05 ROBOT-ASSISTED LAPAROSCOPIC EXTRAVESICAL BILATERAL URETERAL REIMPLANTATION: LUAA TECHNIQUE

You have accessJournal of UrologyCME1 Apr 2023V04-05 ROBOT-ASSISTED LAPAROSCOPIC EXTRAVESICAL BILATERAL URETERAL REIMPLANTATION: LUAA TECHNIQUE Parviz Hajiyev, Jared Fialkoff, and Mohan Gundeti Parviz HajiyevParviz Hajiyev More articles by this author , Jared FialkoffJared Fialkoff More articles by this author , and Mohan GundetiMohan Gundeti More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003252.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In today's era of minimally invasive surgery, robotic-assisted laparoscopic ureteral reimplantation (RALUR) is being popularly performed at many centers. We previously described the LUAA technique (Eur Urol 2016; 70(5):818–823). METHODS: Through this video, we share the step-by-step technical details of the “LUAA” (L-length of ureteric tunnel, U- the u stitch at UVJ, A- placement of the ureteral apical alignment suture and A- ensuring inclusion of adequate ureteral adventitia in detrusorrhaphy) for bilateral ureteric reimplantation. A 4 years old girl presented with recurrent urinary tract infections (UTI) . Her voiding cystourethrogram (VCUG) was suggestive of bilateral high grade of vesicoureteric reflux (VUR), and DMSA scan showed multiple scars. RESULTS: For this persistent bilateral VUR with breakthrough UTIs beyond the age of toilet training, she underwent a robotic-assisted laparoscopic ureteric reimplantation- bilateral (RALUR-b) by the “LUAA” technique. CONCLUSIONS: Postoperative she had USS one month and one year and was normal. The VCUG at 4 months showed resolved VUR bilateral. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e339 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Parviz Hajiyev More articles by this author Jared Fialkoff More articles by this author Mohan Gundeti More articles by this author Expand All Advertisement PDF downloadLoading ...

V04-06 ROBOTIC ASSISTED TRANS-VESICOSCOPIC URETERIC REIMPLANTATION IN CHILDREN: SURGICAL ERGONOMICS RELATED TO MUSCULOSKELETAL SYMPTOMS

You have accessJournal of UrologyCME1 Apr 2023V04-06 ROBOTIC ASSISTED TRANS-VESICOSCOPIC URETERIC REIMPLANTATION IN CHILDREN: SURGICAL ERGONOMICS RELATED TO MUSCULOSKELETAL SYMPTOMS MS Ansari, Prabhu Karunakaran, Sanjoy Sureka, and Priyank Yadav MS AnsariMS Ansari More articles by this author , Prabhu KarunakaranPrabhu Karunakaran More articles by this author , Sanjoy SurekaSanjoy Sureka More articles by this author , and Priyank YadavPriyank Yadav More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003252.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robot-assisted surgery has been reported to provide many benefits over open surgeries to the patient and surgeon. Many surgeons experience work-related pain and musculoskeletal symptoms. Neck strain, back strain/pain and lower extremity exertion have been reported up to 20-40% of the surgeons in open surgeries. We sought to evaluate the feasibly of robotic assisted trans-vesicoscopic ureteric reimplantation in children and surgeons' work-related musculoskeletal symptoms in comparison to open surgery METHODS: The children under 12 years of age with vesicoureteric reflux (VUR underwent open) (Group I) and vesicoscopic robotic assisted ureteric reimplantation (VRAUR) (Group II). All surgeries were performed by a single surgeon. For VRAUR the patient was placed in a dorsal lithotomy position. Four ports (Two 8-mm working ports were placed in a straight line drawn along the anterior superior iliac spine and one endoscopic [middle]) 12 mm (Intuitive Surgical, Sunnyvale, CA), was placed 2 cm above the same line and the fourth assistant port of 3 mm was placed 2 cm below the line. The surgeons related ergonomic parameters recorded in both the groups were generalised pain, neck and back strain/pain along with lower extremity exertion to surgeons (assessed as per visual analogue scale [VAS]). Success was defined as the absence of VUR on direct radionuclide cystogram at 12 weeks. RESULTS: The median age of the children was 4.5 and 5.1 in groups I and II respectively. Both the groups had 30 of patients each. The grades of VUR was comparable in both the groups. The VRAUR procedure could be accomplished in all the cases without any slippage of robotic ports or clashing of arms except in 2-year-old that without any conversion. The 2-yr-old child with bladder capacity of 150 cc posed little difficulty due to space restriction and slight clashing of arms that lengthened the procedure but could be completed successfully. The mean operative time was 95 (90-122) and 140 (115-160) minutes (p=0.029) in groups I and II respectively with a successes rate of 96.7 and 93.3 (p=0.031) respectively. The Surgeons’ musculoskeletal VAS scores recorded were substantially more in Group I as compared to Group II (p value 0.03, OR 3.9 [1.9-5.4]). CONCLUSION: Robotic assisted laparoscopic ureteral reimplantation is feasible and offers success rate comparable to open surgery. The surgical ergonomics related to musculoskeletal symptoms are more substantial in open surgery. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e339 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information MS Ansari More articles by this author Prabhu Karunakaran More articles by this author Sanjoy Sureka More articles by this author Priyank Yadav More articles by this author Expand All Advertisement PDF downloadLoading ...

Comparison of open and robotic-assisted laparoscopic ureteral reimplantation in children with high grade (IV-V) vesicoureteral reflux: A multi-institutional comparative study

Comparison of open and robotic-assisted laparoscopic ureteral reimplantation in children with high grade (IV-V) vesicoureteral reflux: A multi-institutional comparative study

Cumulative sum analysis for the learning curve of robot-assisted laparoscopic ureteral reimplantation surgery in children

Cumulative sum analysis for the learning curve of robot-assisted laparoscopic ureteral reimplantation surgery in children

Minimally invasive ureteral reimplantation or endoscopic management for primary obstructive megaureter: a narrative review of technical modifications and clinical outcomes.

Primary obstructive megaureter (POM) has various courses in different age populations. Although open ureteral reimplantation (OUR) remains the standard treatment for symptomatic POM, it is highly invasive with potential complications. In recent years, minimally invasive ureteral reimplantation (MIUR), including laparoscopic ureteral reimplantation (LUR) and robotic-assisted laparoscopic ureteral reimplantation (RALUR), and endoscopic management, such as double-J stent insertion, endoureterotomy and endoscopic balloon dilatation (EBD), have been utilized for POM in selected patients. However, few comparable studies between MIUR and endoscopic management have been published to date, and it remains unclear which surgical management is the optimal choice for POM in different age groups. This review provides a comprehensive perspective on technical development and clinical outcomes of MIUR and endoscopic management for POM in pediatric and adult populations. The PubMed and Web of Science databases were used to comprehensively search English language articles related to MIUR and endoscopic management for POM in pediatric and adult populations up to March 2022. The technical modifications and the relevant clinical outcomes were reviewed. MIUR with various technical modifications related to intracorporeal suturing and ureteroneocystostomy with anti-reflux techniques appears to be as safe and effective for POM in different age groups as the open procedure. Double-J stent insertion should be regarded as a temporary option for infants by achieving internal urinary drainage, as it may present limited success rates and various complications. Endoureterotomy using pure cutting current or laser appears to be a safer, easier, and less invasive alternative to open surgical management. While EBD has emerged as a definite treatment for POM in the pediatric population, it is debatable whether EBD can substitute for MIUR in adult patients. The safety and feasibility of MIUR and endoscopic management in patients from all age groups still need further investigation.

Robot-Assisted versus Trans-Umbilical Multiport Laparoscopic Ureteral Reimplantation for Pediatric Benign Distal Ureteral Stricture: Mid-Term Results at a Single Center.

Robot-assisted laparoscopic ureteral reimplantation (RALUR) and trans-umbilical multiport laparoscopic ureteral reimplantation (TMLUR) are both minimally invasive procedures for benign distal ureteral stricture (DUS). However, TMLUR has rarely been reported in published research, thus the difference in mid-term outcome of these two procedures warrants investigation. Patients who underwent RALUR or TMLUR for pediatric DUS from April 2017 to November 2020 at our institution were retrospectively analyzed and 56 patients were included in this retrospective comparison. Demographic characteristics, perioperative data and follow-up results were collected and analyzed in RALUR and TALUR groups. RALUR and TMLUR were successfully performed in children aged from 12.0 to 142.0 months, without conversion to open ureteral reimplantation. RALUR took shorter operative time than TMLUR (p = 0.005) with less blood loss (p = 0.001). Meanwhile, patients receiving RALUR encountered a greater financial burden (p &lt; 0.001) with less cosmetic satisfaction than TMLUR. The mean mid-term follow-up time for RALUR and TMLUR was 18.29 months and 24.64 months, respectively. Mid-term follow-up data showed that DUS was relieved with improved renal function after surgery in both groups, with no significant difference. RALUR and TMLUR are both safe and efficient for DUS treatment and achieve comparable mid-term outcomes in children. RALUR can reduce operative time and operative blood loss benefiting from its prominent technical superiority, but may currently bring about greater financial burden, with cosmetic satisfaction remaining to be improved.

Incidence and resolution of de novo hydronephrosis after pediatric robot-assisted laparoscopic extravesical ureteral reimplantation for primary vesicoureteral reflux

With the advent of robot-assisted laparoscopic ureteral reimplantation (RALUR) for primary vesicoureteral reflux (VUR), understanding and minimizing its complications continues to be critical. Incidence of de novo hydronephrosis after RALUR could be indicative of an outcome that needs further study or could be a benign transient finding. In the present study, we hypothesized that the incidence of de novo hydronephrosis after RALUR is low and resolves spontaneously. An IRB-approved prospective single-institutional registry was utilized to identify all patients undergoing RALUR via an extravesical approach from 2012 to 2020. Patients with primary VUR and minimal (Grade I SFU) or no hydronephrosis prior to surgery were included. Patients who had other associated pathology or underwent concomitant procedures were excluded. Preoperative characteristics including VUR and hydronephrosis grades as well as post-operative clinical details and hydronephrosis grades were aggregated and analyzed. 86/172 (50%) patients (133 ureters), with median reflux grade of 3 (IQR: G2, G3) met the inclusion criteria. Patients underwent RALUR at a median age of 5.7 years (IQR: 3.4, 8.7) with median 36.2 months (IQR: 19.6, 63.6) follow-up. Renal ultrasound at 4-6 weeks post-op showed de novo hydronephrosis in 18 (13.5%) ureters; the complete resolution was seen in 13 ureters (72%) at a median of 4.5 months from surgery. Among the 5 with non-resolved hydronephrosis (SFU G2:4, G3:1), 2 patients (3 ureters) underwent subsequent interventions. The present study evaluating the natural history of de novo hydronephrosis after RALUR-EV performed for primary VUR, is to our knowledge the largest cohort of patients undergoing RALUR that this has been studied in. In our cohort, the incidence of de novo hydronephrosis after RALUR was 13.5%, similar to rates reported in two OUR cohorts, and significantly lower than reported incidence rates of 22-26% in several OUR cohorts, and 30% in a RALUR cohort. In the present cohort, hydronephrosis resolved spontaneously in more than 72% of cases. The median time from surgery until resolution of hydronephrosis was 4.5 (1.6, 10.5) months, which is shorter in comparison to the average time to resolution of 7.6 months, reported by Kim etal. in an earlier study. De novo hydronephrosis after RALUR can be followed with serial renal ultrasounds. The majority of de novo hydronephrosis post-RALUR is transient and resolves spontaneously within a year of surgery with a very low re-intervention rate.

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

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

Outcomes of complex robot-assisted laparoscopic ureteral reimplantation after failed ipsilateral endoscopic treatment of vesicoureteral reflux

Endoscopic injection (EI) has been considered a minimally invasive option with high success rates. However, in clinical settings where EI has failed, and after repeat injections or worsening clinical presentation, different treatment modalities may be offered. Open ureteral reimplantation has emerged as a safe option in patients who have failed EI for VUR treatment. Currently there is limited literature describing success of complex robot-assisted laparoscopic ureteral reimplantation (RALUR) following primary EI for vesicoureteral reflux (VUR). We aim to describe our surgical technique and outcomes using RALUR approach following failed EI for VUR. We hypothesize RALUR can be a safe, salvage option in patients who have failed EI for VUR in the setting of recurrent VUR or ureterovesical junction obstruction (UVJO). A single site, retrospective study using electronic medical records of all patients who underwent RALUR between 2013 and 2019 following history of previous ipsilateral EI using dextranomer/hyaluronic acid (DHA) for diagnosis of vesicoureteral reflux (VUR) was conducted. Primary outcomes were radiographic resolution and/or clinical resolution. A total of 17 RALUR procedures were reviewed in 16 patients. There were 14 females (87.5%) and 2 males (12.5%). Seven patients had two prior EI. Median (range) age at time of RALUR was 10.1 (5.7-17.9) years, and the average time between EI and RALUR was 5.9 years [1-13]. The average VUR recurrence grade after failed EI was 3 (ranges 2-4) on preoperative VCUG. History of bilateral EI using dextranomer/hyaluronic acid (DHA), was observed in 14 patients. Surgical diagnosis at time of RALUR included persistent VUR (N=10) or symptomatic ureterovesical junction obstruction (UVJO, N=6). Mean console times were 102min (range 70-240min) for RALUR vs 128min (range 70-180min) for cases requiring ureteral tailoring. Six complications occurred in 16 patients (37.6%): Using the Clavien-Dindo classification scale, four patients (25%) were grade I, one (6.3%) grade II, and one (6.3%) was grade IIIb, which required additional procedures for ureteral obstruction. RALUR after failed EI should be considered a reasonably safe and effective surgical approach in older children with persistent VUR or acquired UVJO.

P0357 - Robot-assisted laparoscopic ureteral reimplantation: Very often successful, which type of failures?

P0357 - Robot-assisted laparoscopic ureteral reimplantation: Very often successful, which type of failures?

Preoperative Bladder Bowel Dysfunction Is the Most Important Predictive Factor for Postoperative Urinary Retention After Robot-Assisted Laparoscopic Ureteral Reimplantation via An Extravesical Approach: A Multi-Center Study.

Introduction: Postoperative acute urinary retention (pAUR) is a known occurrence after robot-assisted laparoscopic ureteral reimplantation via an extravesical approach (RALUR-EV). We hypothesized that the risk factor of pAUR after RALUR-EV might be similar to that of pAUR after open reimplantation. We aimed at performing a retrospective multi-institutional study to evaluate the risk factors for pAUR after RALUR-EV. Materials and Methods: Perioperative data collected from two tertiary referral hospitals included demographics and perioperative variables such as bladder bowel dysfunction (BBD) status, vesicoureteral reflux (VUR) grade, and laterality. pAUR was defined as the need for urethral catheter replacement after removal of the initial postoperative catheter. Univariate and multivariate analyses were performed to identify risk factors for pAUR. Results: A total of 117 patients with 174 renal units from the 2 hospitals were enrolled in this study. The median age at the time of surgery was 5 (0.3-19) years. Bilateral RALUR-EV was performed in 57 (48.7%) cases. pAUR rate was 3.4% in all patients and 7.0% in 57 patients with bilateral VUR. All four cases of pAUR occurred after bilateral surgery. Univariate analysis showed age (p = 0.037), weight (p = 0.039), height (p = 0.040), and bilaterality (p = 0.037) as risk factors of pAUR. In a multivariate analysis, BBD was the only significant risk factor of pAUR (p = 0.037). Conclusion: Urinary retention after RALUR-EV occurred less frequently when compared with the previously reported open surgery series. pAUR was seen only in bilateral cases in our series. Preoperative history of BBD, but not male gender or length of surgical time, was the only risk factor of pAUR after RALUR-EV.

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.

WITHDRAWN: Open versus Robot-assisted Laparoscopic Ureteral Reimplantation: Hospital Charges Analysis and Outcomes at a Single Institution

Robot-assisted laparoscopic extravesical ureteral reimplantation has previously been described as a viable minimally invasive option to open surgery. However, concerns for robotic surgery have been raised owing to assumed higher costs and heterogeneous clinical outcomes. We hypothesized that similar hospital charges and clinical outcomes occur when comparing open and robotic cases in matched cohorts. Open and robotic reimplantation cases from 2013 to 2015 for primary vesicoureteral reflux were matched by age using 1:1 nearest neighbor matching. The matched cohorts were analyzed and compared for their direct itemized hospital charges per surgical case, complications, and clinical outcomes. There were 38 patients in each group after age-matching the 135 patients. Operating room charges were higher for the robotic group compared to the open group (p=0.002), whereas pharmacy and laboratory costs were lower for the robotic group. However, there were no significant differences in total overall charges between the open and robotic groups with cystoscopy or without cystoscopy (p=0.345, p=0.533), since the median hospital stay length was shorter for the robotic group (p<0.001). Clinical success rates were identical for the two groups (open 94.8% vs robotic 94.8%). There were also no significant differences in number of complications between the two cohorts. This is the first age-matched study comparing hospital charges and clinical outcomes of pediatric open and robotic reimplantation. While operating room charges were higher for the robotic cohort, lower hospitalization charges led to comparable overall hospital charges, as well as equivalent clinical outcomes for both cohorts. Level III (Retrospective comparative study) TYPE OF STUDY: Retrospective Study.

Efficacy of robot-assisted laparoscopic ureteral reimplantation for primary obstructive megaureter in children

Objective To evaluate the clinical efficacy of robot-assisted laparoscopic ureteral reimplantation (RAUR) for primary obstructive megaureter (POM) in children. Methods Twenty-one patients who underwent RAUR for POM in Bayi Children’s Hospital between 2017 April and 2018 April were retrospectively analyzed. The study population consisted of 15 boys and 6 girls aged between 2 months and 11 years. Ten patients had left POMs, 9 had right POMs and two had bilateral POMs. All patients were preoperatively diagnosed with a POM based on urinary system ultrasonography, magnetic resonance urography, and diuretic renal dynamic imaging. Our main technique key steps include: Under general anesthesia, the patients were placed in a Trendelenburg position approximately 40 degrees from the horizon. An 8.5-mm camera port was placed at the level of the umbilicus. Followed by two 5-mm robotic Trocars placed under direct vision 6 cm to the camera port separately, a 5-mm assistant port was placed on the right upper abdominal quadrants which was located 3 cm from the camera and robotic port. The ureter was identified at the pelvic brim. The peritoneum covering the ureter was incised and the ureter was mobilized to the level of the vesico-ureteric junction. The bladder was filled with 60 ml saline and a 5 cm length and 1.5 cm wide submucosal detrusor tunnel was created. The ureter was transected at the bladder mucosa and the narrowed ureteral segment was discarded. The ureteroneocystostomy was performed using 6-0 absorbable suture. Dissecting the perivesical fascia appropriately and using down-top suturing approach, use of an apical stay stitch, and incorporation of the ureteral adventitia during detrusorraphy. Postoperative complications were analysed using the Clavien-Dindo classification. Success was defined as symptomatic relief, decreased hydronephrosis on ultrasound and no evidence of vesicoureteral reflux on voiding cystourethrography. Results All surgeries were successfully completed without conversion and no intra-operative complication was encountered. The mean operative time was 117.6±18.1(89-165)min, the mean estimated blood loss was 11.9±4.3(5-25)ml, the abdominal drainage tubes were removed after a mean of 4.9±1.1(3-8)days, and the mean postoperative hospital stay was 6.3±1.3(4-10) days. Postoperative complications (Clavien Ⅰ-Ⅱ) occurred in 9.5% (two patients had recurrent urinary tract infections postoperatively) children, no grade Ⅲ-Ⅳ complication was observed. The pre-operative symptoms in all patients disappeared. One patient had grade Ⅱ VUR on VCUG, who were followed conservatively. Ultrasound at postoperative follow-up showed that the hydronephrosis was disappeared in 20 ureters and significantly decreased in 3 ureters. The success rate was 95.7% at a mean follow-up of 16.3±4.0(10-23)months. Conclusion RAUR is a safe and feasible option for the treatment of POM in children with higher success rate and lower complication rate. Key words: Laparoscopes; Robot-assisted; Ureter reimplantation; Primary obstructive megaureter; Children

Does de novo hydronephrosis after pediatric robot-assisted laparoscopic ureteral re-implantation behave similarly to open re-implantation?

While open ureteral re-implantation surgery is the gold standard for surgical correction of vesicoureteral reflux (VUR), robot-assisted laparoscopic ureteral re-implantation via an extravesical approach (RALUR-EV) has become a minimally invasive alternative. Previous studies have shown that transient hydronephrosis after open re-implantation can occur in up to 28% of patients. However, previous studies have also shown that de novo hydronephrosis after open re-implantation is not predictive of final differential renal function. A retrospective review was performed to characterize the natural history of postoperative hydronephrosis after RALUR-EV for primary VUR in pediatric patients. A retrospective chart review of a single-surgeon series was performed for pediatric patients who underwent RALUR-EV for primary VUR. The severity of de novo hydronephrosis was assessed using the Society for Fetal Urology (SFU) grading system via renal ultrasound at the 1-month postoperative follow-up. Renal ultrasound was performed at least every six months. Radiographic success was defined as complete resolution of VUR on the voiding cystourethrogram at the 4-month mark. Patient demographics, surgery duration, length of hospital stay, pre-operative and postoperative VUR grades, and follow-up time periods were collected. Patients with other associated urinary pathology and patients lost to follow-up were excluded from the study. A total of 87 patients (121 kidney units) with primary VUR who underwent RALUR-EV met the inclusion criteria. SFU grade 1-3 hydronephrosis was noted in 30.3% (36/119) of kidney units at the 1-month mark, but 83.9% (26/31) cases with hydronephrosis completely resolved in a median time of 7.9 months (range: 3.4-21.0 months), and all four cases with unresolved hydronephrosis were downgraded to SFU grade 1 without the need for intervention. A radiographic success rate of 96% was demonstrated in this cohort, which is comparable with that of historical open re-implantation series. A similar rate of de novo hydronephrosis was also noted in this cohort when compared with that of previous open re-implantation series, but de novo hydronephrosis after RALUR-EV had a similar or more rapid resolution rate than that previously reported after open intravesical and extravesical re-implantation series. De novo hydronephrosis after RALUR-EV behaves similarly to de novo hydronephrosis after open ureteral re-implantation, where de novo hydronephrosis is present in up to 30% of pediatric patients who underwent RALUR-EV. The hydronephrosis self-resolves without the need for intervention in the overwhelming majority of casesand resolves at a median time of 7.9 months after surgery.