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Predictors of Failure of Robotic Ureteral Reimplantation for Vesicoureteral Reflux in Children
Ardavan Akhavan, MD, Daniel Avery, MD, Thomas Lendvay, MD.
Seattle Children's Hospital, Seattle, WA, USA.

BACKGROUND:Robotic ureteral reimplantation (RUR) has emerged as a safe and effective alternative to open surgery at many institutions. We report our experience with extravesical RUR, specifically looking at reflux resolution and post-operative urinary retention.
METHODS:We retrospectively reviewed all RURs for the principal diagnosis of vesicoureteral reflux by a single surgeon. All patients underwent postoperative voiding cystourethrogram or radionuclide cystogram. Clinical variables were recorded and correlated with outcomes.
RESULTS:Forty four patients underwent a total of 69 ureteral reimplantations. Mean (range) age was 7.1 (1.9 - 17.9) years; length of stay was 2.1 (1 - 6) days; 28 patients had baseline voiding dysfunction. Bilateral repairs were performed in 25 (57%). Ten (23%) patients had prior dextranomer of hyaluronic acid injection. Twelve (27%) underwent simultaneous ureteral stenting. Five (11%) children had intraoperative suprapubic tubes placed at time of surgery due to a history of high post-void residuals pre-operatively. Postoperative cystograms were performed in 100% of patients at a mean (range) of 65 (34 - 133) days. Mean (range) followup was 345 (34-1914) days. Postoperatively, febrile UTI was seen in 4 (9%) patients, none of whom had reflux on followup cystograms. Complications occurred in 5 (11%) patients; they included ureteral obstruction in 2 and ureteral injury in 1 (all requiring stents), as well as ileus and perinephric fluid collection (both managed conservatively). One patient who underwent bilateral repair (2% overall, 4% of bilateral group) experienced postoperative urinary retention lasting 1 month; he had a history of significant voiding dysfunction and was preemptively treated with a suprapubic tube at time of surgery. Postoperatively, 3 of 19 (15.8%) patients undergoing unilateral surgery had contralateral de novo reflux. When considering all 69 reimplanted ureters, 6 (8.7% of ureters, 13.6% of children) demonstrated persistent reflux postoperatively. Persistent reflux was associated with older age (p= 0.036) and female gender (p = 0.030). Neither a history of voiding dysfunction, case number, bilaterality, reflux grade, presence of a duplex system, stent placement at time of surgery, nor history of prior deflux was associated with persistence of reflux.
CONCLUSIONS:Of our 44 children undergoing RUR, 86.4% had no persistent reflux in the affected ureter. This equates to a 91.3% success rate in our reimplanted 69 ureters. Female gender and older age were associated with a higher failure rate.


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