Laparoscopic intravesical ureteral reimplantation: Success rates are equivalent to open repair
Venkata R. Jayanthi, MD.
Nationwide Children's Hospital, Columbus, OH, USA.
BACKGROUND: Open ureteral reimplantation is the gold standard for the surgical management of vesicoureteral reflux (VUR). Robot assisted ureteral reimplantation has become more common but remains controversial due to increased complications and suboptimal outcomes. Our hypothesis is that vesicoscopic ureteral reimplantation (VR)can provide the benefits of minimally invasive surgery with the safety and success of open surgery.
METHODS: We retrospectively reviewed all patients who underwent VR at our institution. We recorded ages, sex, grade of reflux, operative times, outcomes and complications. Only patients with primary VUR requiring a nontapered reimplant were considered to be appropriate candidates. Under carbon-dioxide "pneumovesicum", cross-trigonal reimplantation was done in a manner analgous to open repair. All underwent renal bladder ultrasonogram (RBUS) at 1 month and were offered voiding cystourethrogram (VCUG) at 3 months post-operatively. RESULTS: The series consists of 183 consecutive patients who underwent vesicoscopic repair. There were 165 females and 17 males, mean age 7.03 years (16 months - 38.2 years). Fifteen had failed prior injection therapy. At the time of surgery, mean grade of right reflux was 2.52 and mean grade of left reflux 2.62. Bilateral repairs were done on 136 patients and 47 patients underwent unilateral for a total of 319 ureters. Mean operative time for bilateral repairs was 197 (112-284) minutes and 169 (99-288) for unilateral. Fourteen of the patients were greater than 12 years of age and though the operative times were greater (220 minutes bilateral, 185 unilateral), the differences did not reach statistical significance (p>0.05 for both). Major complications included two who developed ureteral obstruction (1%). One resolved with stent placement and the other underwent reoperative reimplantation. Post-operative VCUG was obtained in 100 patients (176 ureters) which was normal in 93. The seven with persistent reflux included 6 "true" failures and one who developed contralateral reflux after unilateral repair. Eight ureters still showed reflux after surgery suggesting a ureteral-specific success rate of 168/176=95%. Four of these failures occured in the first 30 patients. Of the last 49 patients with postoperative cystograms, 48 were normal suggesting a 98% effective patient- success rate after the learning curve. CONCLUSIONS: Though laparoscopic approaches have taken a primary role in renal surgery, bladder level surgery is still most often done using open techniques. Recent reviews suggest that robot-assisted reimplantation may have suboptimal outcomes. In contrast, our data demonstrate that intravesical laparoscopic ureteral reimplantation is a minimally invasive procedure with success rates equivalent to open repair and with a very low rate of complication. VR may be of particular benefit in older patients where open dissection deep in the pelvis can be difficult.
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