Laparoscopic and Robotic Assisted Laparoscopic reimplantation for lower ureter pathology. Multi institutional comparative study in 1343 patients
Leon Chertin, MD1, Stanislav Kocherov, MD1, Pavel Bakaleyshchik, MD1, Yuri Baranov, MD2, Vitaliy Dubrov, MD3, Iliya Kaganstov, MD4, Sergey Karpachev, MD5, Galina Kuzovleva, MD6, Alexander Pirogov, MD7, Yuri Rudin, MD8, Dmitriy Sablin, MD9, Vladimir Sizonov, MD10, Oleg Shmyrov, MD11, Amnon Zisman, MD1, Boris Chertin, MD12, Amos Neheman, MD13, Sergey Bondarenko, MD14.
1Shamir Medical Center (Assaf Harofeh), Beer Yaakov, Israel, 2Regional Children”s Clinical Hospital,, Ekaterinburg, Russian Federation, 32nd City Pediatric Clinical Hospital, Minsk, Belarus, 4Almazov National Medical Research Center, Saint Petersburg, Russian Federation, 5National Medical Research Center for Chidren”s Health, Moscow, Russian Federation, 6Sechenov University, Moscow, Russian Federation, 7Regional children”s Clinical Hospital named after N. Silishcev, Astrachan, Russian Federation, 8N. Lopatkin’s Research Institute of Urology and Interventional Radiology – branch of the National Medical Research Radiological Centre of Ministry of Health Russian Federation, Moscow, Russian Federation, 9Archangelsk Regional Children’s Clinical Hospital named after P.G. Vyzhletsov, Archangelsk, Russian Federation, 10Rostov Regional Children”s Clinical Hospital, Rostov-on-Don, Russian Federation, 11Shamir Medical Center (Assaf Harofeh), Morozovskaya Children's City Clinical Hospital, Russian Federation, 12Shaare Zedek Medical Center, Jerusalem, Israel, 13Meir Medical Center, Kfar Saba, Israel, 14Regional Hospital 7, Volgograd, Russian Federation.
BACKGROUND: Minimal-invasive surgical (MIS) approaches to ureteral reimplantation have enjoyed wide popularity in the field of pediatric urology during recent years. Success rates with MIS are similar to open reimplantation, however open ureteral reimplantation is still widely considered the gold standard. The aim of this study was to evaluate the outcomes of Laparoscopic Extravesical Ureteral Reimplantation (LEUR), Laparoscopic Vesicoscopic Cross-Trigonal Ureteric Reimplantation (LVCUR), Laparoscopic Dismembered Extravesical Cross-Trigonal Ureteral Reimplantation (LDECUR), Robotic Assisted Laparoscopic Extravesical Ureteral Reimplantation (RALUR) and Robot Assisted Laparoscopic Dismembered Extravesical Cross-Trigonal Ureteral Reimplantation (RADECUR) in children with VUR and obstructive megaureter in terms of effectiveness and morbidity in a multicenter study.
Methods: This is a retrospective review of all pediatric minimal invasive cases for lower ureter pathology performed between the years 2016-2022 in 13 academic centers worldwide. Demographics, perioperative surgical data, complications, and results are described. Five surgical approaches were assessed: LEUR, LVCUR,LDECUR,RALUR and RADECUR. RESULTS: Overall, 1343 patients (490 boys and 853 girls) with a median age of 30 month (IQR 12-63) were treated at 13 centers worldwide utilizing MIS. 908 patients (68%) underwent reimplantation due to VUR (unilateral in 818 and bilateral in 90 patients) comprising 998 renal refluxing units (RRUs). Reflux was grade I-V in 34 (2%), 143(14%), 512 (51%), 198 (20%), and 111 (13%) RRUs respectively. 435 (32%) had a surgery due to UVJ obstruction. Of those, 15 (3%) had bilateral pathology. 307 patients (22%) underwent LEUR, 757 (56%) LVCUR, 189 (14%) LDECUR, 10 (1%) RALUR, and the remaining 80 (7%) patients underwent RADECUR. Mean length of follow up was 14 month (IQR 8-33). Median operative time was 202 minutes (IQR 142-220) in the robotic arm compared to 240 minutes (IQR 160-267) in the laparoscopic arm not related to type of surgical approach (p=0.45). Intracorporeal excisional tapering was performed in 118 (8%) of the patients. 14 (1%) patients in the laparoscopic group required extracorporeal tapering. Grade 1-2 Clavien-Dindo complications occurred in 10 patients (0.7%) and 6 (0.4%) in the laparoscopic and robotic arm respectively. Grade 3 complication occurred in 17 (1.2% and 8 (0.5%) in both arms respectively. Conversion to an open procedure occurred in 9 (0.06%) patients, all in the laparoscopic cohort. Surgical success was achieved in 96% of patients regardless of the surgical approach. CONCLUSIONS: The results of this multicenter survey confirm that Laparoscopic and Laparoscopic Robotic Assisted approaches are simple, safe, and effective for treating all grades of VUR and obstructive megaureter. Robotic assisted approach is beneficial in terms of operative time, intracorporeal suturing and lower complications rate.
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