Is pelvic plexus nerve documentation feasible during robotic assisted laparoscopic ureteral reimplantation with extravesical approach?

Surgical management of vesicoureteral junction obstruction (VUJO) in children: A comparative study between transvesicoscopic Cohen reimplantation and transumbilical laparoendoscopic single-site (TU-LESS) Lich-Gregoir techniques

BACKGROUND

There are many reports on the application of minimally invasive technology in the correction of children's VUJO, but there is no report on the treatment of children's VUJO by the TU-LESS Lich-Gregoir method. We aimed to comparatively analyze the therapeutic outcomes of transvesicoscopic ureteral reimplantation Cohen procedure (TUR-C) and TU-LESS surgery Lich-Gregoir procedure (TU-LESS-LG) in pediatric VUJO.

METHODS

The data of 49 children with VUJO admitted from January 2016 to January 2020 were retrospectively analyzed. Based on different surgical methods, they were divided into the TUR-C group (23 cases) and the TU-LESS-LG group (26 cases). The demographic characteristics, perioperative characteristics, postoperative complications, the recovery of renal function, and the improvement of hydronephrosis were compared between the two groups.

RESULTS

There were no statistical differences in demographic characteristics and preoperative data between the two groups. The TU-LESS-LG group was superior to the TUR-C in terms of average operation time and postoperative hospital stay. There was no statistical difference between the two groups in terms of postoperative complications, postoperative recovery of renal function, and improvement of hydronephrosis.

CONCLUSION

The two surgical methods can achieve a similar curative effect in the treatment of VUJO. The TU-LESS-LG has more advantages in operation time, postoperative hospital stays, the wider age selection range of cases, megaureter tapering, and cosmetic incision, but the operation is more difficult.

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

BACKGROUND

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.

OBJECTIVE

To assess the safety and efficacy of RALUR-EV in children, among experienced surgeons.

DESIGN AND METHODS

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.

RESULTS

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.

DISCUSSION

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.

CONCLUSIONS

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.

Current status of robotic-assisted surgery for the treatment of vesicoureteral reflux in children

PURPOSE OF REVIEW

Although open ureteral reimplantation remains the gold standard for surgical correction of vesicoureteral reflux (VUR), robotic-assisted laparoscopic ureteral reimplantation (RALUR) holds promise and is becoming more widely utilized. The present article outlines primary operative techniques for RALUR, summarizes the current literature with respect to surgical outcomes and costs, and discusses early applications of RALUR to complex and reoperative cases.

RECENT FINDINGS

Intravesical and extravesical techniques for RALUR have been described. Published outcomes vary with respect to operational definitions of surgical success and reporting of complications. Several studies have directly compared RALUR and open reimplant, suggesting equivalent efficacy and safety. Recent noncomparative studies have reported lower VUR resolution rates and higher complication rates for RALUR, particularly in bilateral cases. The application of RALUR to reoperative surgery and cases requiring tapering and dismemberment is under very early investigation. RALUR is consistently associated with lower postoperative analgesic requirements and decreased hospital stay, but longer operative times and higher costs compared to open reimplant.

SUMMARY

Published outcomes after RALUR show mixed results that, on average, may be inferior to open reimplant. Future investigations should seek to identify patient-related and intraoperative factors associated with successful and unsuccessful outcomes.

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

INTRODUCTION

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.

OBJECTIVES

To compare postoperative outcomes after bilateral robot-assisted laparoscopic ureteral reimplantation to unilateral robot-assisted laparoscopic ureteral reimplantation.

STUDY DESIGN

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.

RESULTS

92 patients with a median follow-up of 14 (25th and 75th IQR 5, 28) months. Median operative time (150 vs. 178 min, p = 0.01) and median hospital stay (33 vs. 37 h, 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).

DISCUSSION

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 could help outcomes after bilateral ureteral reimplantation. Limitations of this study include its retrospective design, the absence of routine postoperative VCUG after ureteral reimplantation, and unknown confounding variables.

CONCLUSION

Robot-assisted laparoscopic bilateral extravesical ureteral reimplantation is not associated with an increased risk of postoperative morbidity compared with unilateral surgery.

Lessons learned over a decade of pediatric robotic ureteral reimplantation

The da Vinci robotic system has improved surgeon dexterity, ergonomics, and visualization to allow for a minimally invasive option for complex reconstructive procedures in children. Over the past decade, robot-assisted laparoscopic ureteral reimplantation (RALUR) has become a viable minimally invasive surgical option for pediatric vesicoureteral reflux (VUR). However, higher-than-expected complication rates and suboptimal reflux resolution rates at some centers have also been reported. The heterogeneity of surgical outcomes may arise from the inherent and underestimated complexity of the RALUR procedure that may justify its reclassification as a complex reconstructive procedure and especially for robotic surgeons early in their learning curve. Currently, no consensus exists on the role of RALUR for the surgical management of VUR. High success rates and low major complication rates are the expected norm for the current gold standard surgical option of open ureteral reimplantation. Similar to how robot-assisted laparoscopic surgery has gradually replaced open surgery as the most utilized option for prostatectomy in prostate cancer patients, RALUR may become a higher utilized surgical option in children with VUR if the adoption of standardized surgical techniques that have been associated with optimal outcomes can be adopted during the second decade of RALUR. A future standard of RALUR for children with VUR whose parents seek a minimally invasive surgical option can arise if widespread achievement of high success rates and low major complication rates can be obtained, similar to the replacement of open surgery with robot-assisted laparoscopic radical prostectomy as the new strandard for men with prostate cancer.

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

BACKGROUND

Robot-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.

OBJECTIVE

To describe technique modifications that may lead to improved radiographic vesicoureteral reflux (VUR) resolution.

DESIGN, SETTING, AND PARTICIPANTS

Between 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 PROCEDURE

We 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 ANALYSIS

The primary end point was resolution of VUR on postoperative VCUG.

RESULTS AND LIMITATIONS

Because 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.

CONCLUSIONS

Using 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 SUMMARY

We 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.

Robot-assisted extravesical ureteral reimplantation: outcomes and conclusions from 78 ureters

OBJECTIVE

Extravesical robot-assisted laparoscopic ureteral reimplantation (RALUR) is a popular alternative to open surgery. We report our experience with RALUR and evaluate clinical variables as predictors for failure.

METHODS

We retrospectively evaluated the records of patients who underwent RALUR by a single surgeon for treatment of primary vesicoureteral reflux. Clinical and demographic variables were determined. Clinical variables were compared with surgical outcomes using the Student two-tailed type 2 t test.

RESULTS

Fifty patients underwent a combined 78 extravesical RALURs. Median (range) age was 6.2 (1.9-18.0) years; median (range) preoperative reflux grade was 3 (0-5). Dysfunctional elimination syndrome (DES) was present in 32 (64%). Ten (20%) patients had prior deflux, and two (4%) had prior ureteroneocystostomy on the ipsilateral side. Postoperative cystogram was performed in 100% at a median (range) of 55 (27-133) days. Median (range) follow-up was 286 (27-2238) days. Febrile urinary tract infection occurred in five (10%), none of whom had reflux on initial follow-up postoperative cystogram. All five had a history of DES and were female. Six complications occurred in five (10%) patients, including ileus (2), ureteral obstruction (2), ureteral injury (1), and perinephric fluid collection (1). Transient urinary retention occurred in one. Five of 22 (22.7%) patients undergoing unilateral surgery had contralateral de novo reflux. Six of 78 ureters (7.7%) had persistent reflux postoperatively. Neither persistent nor de novo reflux was associated with any of the clinical variables assessed.

CONCLUSIONS

RALUR is an effective and safe option for patients with primary vesicoureteral reflux requiring surgery.