Is Common Sheath Extravesical Reimplantation an Effective Technique to Correct Reflux in Duplicated Collecting Systems?

Postoperative hydronephrosis following ureteral reimplantation: Clinical significance and importance of surgical technique and experience

BACKGROUND

Though common, postoperative hydronephrosis (POHN) following ureteroneocystostomy raises concern for an underlying obstruction. We aimed to determine the clinical significance of POHN following open (OUR) or robotic (RALUR) ureteral reimplantation.

METHODS

We retrospectively reviewed pediatric patients who underwent ureteral reimplantation for vesicoureteral reflux (VUR) from 2008 to 2019 by a single surgeon. Baseline characteristics, operative outcomes, and trends in POHN were assessed. POHN was defined as new onset hydronephrosis or exacerbation of pre existing hydronephrosis. Renal ultrasounds were performed 1, 4, and 12 months postoperatively. Voiding cystourethrograms were performed 4 months postoperatively. Surgical experience for RALUR cases was defined as number of ureters operated over time.

RESULTS

Altogether, 93 patients (127 ureters) underwent RALUR and 19 patients (26 ureters) underwent OUR. POHN was found in 27.6% and 30.8% of ureters after RALUR and OUR, respectively. Rate and time to POHN resolution for RALUR (91.4%, 112 days) and OUR (75%, 211 days) were statistically similar. Odds of POHN after RALUR were directly related with preoperative VUR grade (Range OR: 2.82[2.26-3.52]) and surgical experience (Range OR: 8.88[7.16-11.02]). Surgical experience was inversely related with odds of VUR recurrence (Range OR: 0.41[0.32-0.54]). Rates of VUR resolution were comparable for OUR and RALUR patients. No patient required additional intervention for POHN.

CONCLUSIONS

Incidence and resolution rate of POHN after OUR and RALUR were similar. Higher VUR grades were associated with increased odds of POHN after RALUR. Increasing RALUR experience improved VUR resolution rate but increased odds of POHN. Surgical success rates were similar for RALUR and OUR.

LEVEL OF EVIDENCE

II.

A novel method of transvesicoscopic ureteral reimplantation of an ectopic ureter with a mate ureter in a duplex kidney

Introduction

The reimplantation of an ectopic ureter is still performed as an open surgery, although laparoscopic or robot‐assisted laparoscopic surgery has gained popularity as a minimally invasive treatment for pediatric urological disorders.

Case presentation

A 15‐day‐old Japanese boy was referred to our hospital with right hydronephrosis. A detailed examination revealed complete ureteral duplication on the right side and a dilated ectopic upper pole ureter, opening into the prostatic urethra. Since the patient had recurrent febrile urinary tract infections, we performed plication and ureteral reimplantation of the dilated ectopic ureter using a transvesicoscopic surgical method at the age of 2 years and 5 months.

Conclusion

We safely performed transvesicoscopic ureteral reimplantation for an ectopic upper pole ureter with a mate ureter in a duplex kidney, following the detection of an ectopic ureter within the bladder, due to the prior understanding of the wrapping of both ureters in a common sheath.

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.

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

BACKGROUND

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.

OBJECTIVE

A retrospective review was performed to characterize the natural history of postoperative hydronephrosis after RALUR-EV for primary VUR in pediatric patients.

STUDY DESIGN

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.

RESULTS

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.

DISCUSSION

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.

CONCLUSION

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 cases and resolves at a median time of 7.9 months after surgery.

An Inguinal Approach to Complex Extravesical Ureteral Reimplantation

OBJECTIVE

To report our experience in applying the Lich-Gregoir extravesical ureteral reimplantation (EVR) approach to complex cases (megaureter, duplex systems) through a small inguinal incision, with the goal of minimizing invasiveness.

MATERIALS AND METHODS

We reviewed the records of all patients who underwent common sheath or tapered EVR through an inguinal incision. Patient characteristics and reflux grade were obtained, and outcomes were assessed. The technique involved a 2-cm incision made in the lowest inguinal skin crease, standard cord exposure and lateral retraction, and opening the floor of the canal to isolate the ureter. Excisional tapering was performed with the ureter dismembered from the bladder and then reimplanted via detrusorrhaphy, whereas common sheath reimplantation was performed with advancement fixation sutures and the ureters in situ.

RESULTS

Twenty-eight patients (15 males and 13 females) with a median age of 1.7 years (range: 0.9-4.8 years) were included. Fifteen patients had ureteral tapering, 12 underwent common sheath reimplantation, and 1 child had both. Success was seen in 94% for tapering and 92% for common sheath reimplants, with a mean follow-up of 29.6 months. There were no postoperative obstructions, urinary leaks, or wound infections.

CONCLUSION

The inguinal approach can safely and effectively be applied to cases of extravesical ureteral tapering and common sheath reimplantation.

Robot-assisted laparoscopic management of duplex renal anomaly: Comparison of surgical outcomes to traditional pure laparoscopic and open surgery

INTRODUCTION

Surgical management of duplex renal anomaly (DRA) is complex because of individual anatomic variation, competing priorities of vesicoureteral reflux (VUR) and ureteral obstruction present in the same child, the varied differential function of the different renal moieties, and the presence of voiding dysfunction and recurrent urinary tract infection (UTI). Robot-assisted laparoscopic (RAL) surgical management has been under-reported in this group of children but is becoming a viable alternative to traditional open surgery.

OBJECTIVE

The aim was to report the surgical outcomes of a series of children with DRA who had RAL surgery and compare these outcomes to historical cohorts of open and laparoscopic surgery.

STUDY DESIGN

This was a retrospective analysis of a prospective series of children who had RAL surgery for DRA over an 8-year period. Forty-five RAL surgeries were performed in 47 children. RAL heminephrectomy (RAL HN) was performed in 19 children for poorly or non-functional renal moiety. One had staged bilateral RAL HN. RAL ureteroureterostomy (RAL UU) was performed in 14 children for upper pole ureteral obstruction. Thirteen RAL common sheath ureteral reimplants (RAL csUN) with or without ureteral tapering were performed in 12 children with VUR and UTI. Diagnosis and demographics, results of preoperative imaging, intraoperative time stamps, perioperative complications, success rate, and renal outcomes were recorded.

RESULTS

Low-grade VUR present preoperatively in the RAL UU group all resolved within the follow-up period. Four (25%) children in the RAL HN group developed de novo VUR after surgery, which resolved in two (50%) and required surgery in two (50%). Grade I VUR after RAL csUR that occurred in two (14.3%) children was asymptomatic and observed when off preventative antibiotics.

DISCUSSION

Most children with DRA who need surgical treatment can be offered RAL surgery. We report good outcomes and improved operative times for RAL HN and UU that approach historical open and pure laparoscopic cohorts. However, RAL csUR, especially with ureteral tapering, is more complex and inherently susceptible to complications, and has not met the outcomes of the open gold standard. The limits of this study are that selection bias is present, and there is no study control cohort.

CONCLUSIONS

This report achieves its aim to report surgical outcomes of children who had RAL surgery for DRA.

Hydronephrosis following ureteral reimplantation: when is it concerning?

OBJECTIVES

Hydronephrosis without obstruction is common prior to ureteral reimplant, especially in patients with high-grade VUR. Consequently, when hydronephrosis is present post-operatively, it is unclear when it should be concerning. We evaluated the finding of hydronephrosis in children undergoing reimplantation and its evolution following surgery.

METHODS

After obtaining IRB approval, we identified 938 children who underwent reimplantation at our institution from 1998 to 2006. Their pre- and post-operative US and clinical course were analyzed.

RESULTS

Hydronephrosis was observed in 24% pre-operatively and 21% post-operatively. 52% with pre-operative hydronephrosis had it post-operatively, while 12% without pre-operative hydronephrosis had it post-operatively. 71% of post-operative hydronephrosis resolved on average in 1.36 years. 19% didn't resolve and 0.1% had ureteral obstruction. Risk factors for post-operative hydronephrosis included increasing severity of VUR, and high degree of pre-operative hydronephrosis.

CONCLUSION

Hydronephrosis following ureteral reimplantation is not rare, and correlated to pre-operative evaluations. Post-operative hydronephrosis is frequently transient and benign, and usually resolves within the first 2 years. These patients do not require follow-up ultrasounds or further imaging, and can be followed clinically. Patients with high-grade VUR and hydronephrosis pre-operatively, however, are at risk for developing worsened hydronephrosis and should be followed with a 3-month post-operative ultrasound.

Single-center experience with pediatric laparoscopic extravesical reimplantation: safe and effective in simple and complex anatomy

PURPOSE

Minimally invasive approaches to the surgical management of vesicoureteric reflux (VUR) have become more prominent over the last 10 years with progress in both endoscopic and laparoscopic/robotic surgery. We hypothesized that laparoscopic extravesical detrussoraphy (LED) for the management of VUR in children with complex bladders and/or bilateral VUR was safe and effective.

SUBJECTS AND METHODS

Under institutional review board approval we evaluated the charts of all patients seen at our institution over the last 8 years who had undergone LED for the management of VUR. We evaluated demographic variables, surgical variables, and postoperative results. Postoperative bladder function was examined in the patients as well as need for secondary procedures. Patients with complex bladders included all patients who had previous surgery on the affected side, neurogenic bladders, and duplex or complex anatomy.

RESULTS

Ninety-eight patients with 144 ureters were treated during this time period. The overall VUR resolution by voiding cystourethrogram was 95.2%. The average age was 6.74 years, with 13 children over the age of 12 years old. Average length of stay (LOS) was 1.7 days for children 5 years and older and 1.0 days for children less than 5 years old (P=.004). LOS was not affected by body mass index or complexity of the procedure. There were 46 bilateral procedures, and the incidence of urinary retention was 6.5% versus 0% in the unilateral group (P=.09). Of our patients, 27.6% had complex bladders, including 9 patients with complete ureteral duplications, 10 with periureteral diverticula, and 8 with prior surgery on the affected side. There were two complications requiring a second procedure in this group (7%). No patient with a complex bladder had persistent VUR.

CONCLUSION

LED for the management of children with complex bladders and VUR is safe and effective. This technique is versatile and achieves high VUR resolution rates with minimal morbidity.

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

INTRODUCTION

Minimally invasive surgery implies a percutaneous or endoscopic approach rather than an incision, regardless of size. However, open approaches to various procedures using a mini-incision should assume the same appellation. We report our experience with extravesical ureteral reimplant (EVR) performed through an inguinal mini-incision.

MATERIALS AND METHODS

Patient characteristics of age, gender, and reflux grade were obtained, and outcomes of recurrent urinary tract infection, time of surgery, time of hospitalization and radiographic resolution were assessed. The technique involved a 2 cm incision made in the lowest inguinal skin crease, standard hernia exposure, opening of the floor of the inguinal canal to isolate the ureter, detrussorhaphy.

RESULTS

30 girls and 15 boys with a mean age of 64 months (range 20-180), and mean followup of 18 months (range 3-36) underwent unilateral inguinal mini-incision EVR. Reflux grades represented were 7, 13, 18, 5, and 2 for Grades I through V respectively. Common sheath reimplantations were performed in twelve duplicated systems, and tapering performed in three patients. The average time of surgery was 75 min. All but 2 patients were discharged within 24 h; postoperative imaging was normal in all cases. Three patients had febrile UTIs following discontinuation of prophylactic antibiotics.

CONCLUSION

The inguinal approach to EVR is safe, effective, efficient, and well-tolerated. Through several maneuvers learned as the experience with EVR grew, we present a realizable approach to minimally invasive ureteral reimplantation with application in most pediatric urologic practice.

The role of the Lich-Gregoir procedure in refluxing duplicated collecting systems: experience from long-term follow up of 45 children

OBJECTIVE

The need for surgical correction of vesicoureteral reflux (VUR) is increased in duplicated systems. The aim of this study was to evaluate the outcome of the Lich-Gregoir procedure (LG) with regard to VUR persistence, contralateral de-novo VUR, hydronephrosis, preservation of split renal function, urinary tract infections (UTI) and postoperative side effects.

PATIENTS AND METHODS

Between 1993 and 2007, 45 children (mean age 3.2 years) underwent a unilateral common sheath LG. A combined number of at least 75 episodes of febrile UTI had occurred in 39 children prior to surgery. VUR grades I to V were present in two, nine, 16, 16 and two children, respectively. Hydronephrosis was present in 18 children. Mean split renal function was 44.03% (range 15-63%). Indications for surgery were febrile breakthrough UTI in 11 children and abscessing pyelonephritis in two. The remainder underwent surgery due to renal scars, reduced split renal function (<45%), VUR persistence and/or parental desire.

RESULTS

Persistent ipsilateral and de-novo contralateral VUR were detected in three children (ipsilateral in one, contralateral in one, bilateral in one), resulting in a 4.4% rate of persistent ipsilateral VUR. One year post surgery, low-grade hydronephrosis persisted in six patients without impact on split renal function. Mean split renal function remained stable at 44.06% (range 15-68%). During follow up (mean 41 months), six febrile UTIs occurred in five girls (92.4% risk reduction, P<0.00000005). Neither urinary retention nor any other side effect was observed.

CONCLUSION

Performed unilaterally, common sheath LG is a safe and effective technique to cure VUR, prevent febrile UTI and maintain split renal function in duplicated systems with otherwise uncomplicated anatomy.

[Long-term experience with Cohen ureteral reimplantation in bilateral vesicoureteral reflux in childhood]

INTRODUCTION

In bilateral VUR, Cohen cross-trigonal ureteric reimplantation is a popular but also controversial surgical approach. We present our own experience in a retrospective analysis.

PATIENTS AND METHODS

Between 1990 and 2005, 41 children (26 girls, 15 boys) with bilateral reflux [92 renal units (RU)] underwent ureteric reimplantation. The mean age was 4.5 (0.3-12) years. Eight patients had ureteral duplication (six unilateral, two bilateral); 12 of 41 patients had no intraoperative ureteral stenting. Seven patients had prior surgery for VUR. A successful result was defined as absence of VUR, significant UVJ obstruction, or voiding dysfunction throughout the follow-up.

RESULTS

The mean follow-up was 7.8 (0.5-15) years. Eight patients (19.5%) had 13 complications. One patient had an intraoperative small bowel lesion (2%). Six patients (14.6%) had UTI. Four patients (9.8%) showed transient UVJ obstruction. Three required a temporary percutaneous nephrostomy. Two of these patients had no intraoperative ureteral stenting. Recurrence of VUR was found in 2 patients (4.8%) and 2/92 RU (2.2%), respectively. Complications were more frequent in high-grade VUR, ureter duplex, or unstented ureteral reimplantation. Prior surgery for VUR did not influence the postoperative outcome. Postoperative voiding disorders were not observed.

CONCLUSIONS

Two unilateral recurrences of VUR were observed, requiring a reoperation in one patient. A reoperation for UVJ obstruction was not necessary. Related to 92 RU the surgical success rate was 97.8%. Intraoperative ureteral stenting has to be considered with respect to the current discussion of shortening inpatient procedures. In our experience, the perioperative risk was elevated in patients with high-grade VUR or ureteral duplication.

Surgical management of vesicoureteral reflux in pediatric patients

Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. The current indications for the surgical correction of VUR depend on the presence or absence of renal scars. If no scars are present, primary ureteral reimplantation is only indicated in high-grade bilateral VUR, whereas in the presence of renal scars surgical correction is indicated in low/high grade reflux at a young age. Since there are numerous techniques for antireflux surgery available, it is the purpose of this article to critically review these techniques with their specific advantages, typical complications and postoperative management. In general, all surgical technique have a high success rate of 92-98%. The extravesical Lich-Gregoir technique is primarily indicated in unilateral VUR. Children with a high-grade VUR, who are under the age of 3 years and boys are prone to the development of postoperative urinary retention and might be considered for intravesical surgical techniques. The Politano-Leadbetter technique is very helpful in correcting bilateral VUR of any grade in one session to create a neo-ostium in an anatomically correct position which is easily accessible for endourological manipulations. The Psoas hitch ureteroneocystotomy is an excellent technique to correct VUR associated with megaureter, or with duplicated ureters, and VUR failures. Endoscopic subureteral injections are primarily reserved for low grade VUR with a one session success rate of >90%. Endoscopic subureteral injections appear to be an alternative to long-term antibiotics in grade I-III VUR. Laparoscopic antireflux surgery has not gained widespread use due to the very long operating times. Contralateral VUR will occur in about 20% of children undergoing unilateral antireflux surgery; risk factors are severe VUR and VUR into a duplicated system. Postoperative follow-up nowadays consists of urinalysis and ultrasonography; voiding cystourethrography is only indicated in case of febrile urinary tract infection. Despite the excellent success rates following antireflux surgery one has to keep in mind that surgery only corrects the anatomical abnormality. The long-term outcome with regard to renal function, posttherapeutic febrile urinary tract infections and arterial hypertension does not differ significantly from the medication group except for those patients with a demonstrated a genetic background. Therefore, the indication for surgery and the surgical technique applied have to be discussed thoroughly and must be associated with a minimal complication rate.