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Complex Robot-Assisted Laparoscopic Ureteral Reimplant: Safety and Outcomes
Bruce W. Lindgren, M.D., Rachel Shannon, B.S., Ilina Rosoklija, MPH, Emilie K. Johnson, MD,, Dennis B. Liu, MD, Edward M. Gong, MD.
Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.

BACKGROUND: Current literature on robot-assisted laparoscopic ureteral reimplant (RALUR) contains a wide range of reported success and complication rates, thus its role remains controversial. Success following open ureteral reimplant with tailoring has been reported at 74-90%. We have utilized RALUR for both straightforward and complex procedures in children. Given the limited available literature, we aim to evaluate our institutional experience with complex RALUR.
METHODS: A retrospective review of RALUR 12/2011 - 2/2019 at a single institution was conducted. Cases were considered complex if RALUR was performed in conjunction with megaureter tapering or ipsilateral ureteroureterostomy (IUU), or if the patient had neurogenic bladder (NGB) or history of kidney transplant. Demographic, operative, and post-operative data for the complex cases were evaluated. Primary outcomes assessed were surgical success (repair of reflux or obstruction) and complications; secondary outcomes assessed included length of hospital stay (LOS), operative time and EBL.
RESULTS: RALUR was performed in 114 patients, with 42 cases considered complex (35 with tapering, 4 RALUR with IUU, 3 in patients with NGB or transplanted kidney). Double-J ureteral stents were placed in 40/42 (95%) and removed cystoscopically at a median duration of 5 weeks. Demographic and perioperative data are shown in Table 1.
Table 1:

n = 42Median (Range)
Age (yr)2 (0.7 - 21)
Weight (kg)14 (8 - 88)
Preoperative imaging: (n)18 VUR* 17 UVJ* Obstruction 5 VUR with UVJ obstruction 2 NRNO* Megaureter
Operative Time (min) -Console time285 (191 - 560) 198 (126 - 388)
Estimated Blood Loss (EBL) (mL)5 (2 - 50)
Length of stay (LOS) (hours)26 (16 - 212)
Follow-up (mo.)18 (1 - 63)

*VUR = Vesicoureteral Reflux; UVJ = Ureterovesical Junction; NRNO =Non-refluxing, Non-obstructed
Post-operative US was available in 33/34 patients with pre-op hydronephrosis (from VUR or obstruction); there was sonographic improvement in 31/33 (94%); the 2 without improvement had persistent hydroureteronephrosis but no obstruction on diuretic renography, confirming relief of obstruction in 22/22 (100%) with pre-op obstruction. Of the 23 patients with VUR, 17 underwent post-op VCUG, with resolution of VUR in 13/17 patients (76%). Overall success for those with post-op imaging was 37/41 (90%). There were no intraoperative complications identified. Two Clavien 2 complications occurred within 60 days, 1 readmission for urinary retention and extravasation and 1 febrile UTI, for a 60-day complication rate of 4.7%. Ultimately 5 patients (13%) required return to the OR at a median of 15 months (5 days - 40 mo) after complex RALUR for diagnostic (n=2), stent-related (n=1) or reoperative (n=2) procedures, including 1 open reoperative repair for persistent reflux (previous plication and reimplant) and 1 with a history of previous open pyeloplasty for recurrent UPJ obstruction after repair of VUR.
CONCLUSIONS: Complex RALUR is a safe procedure and successful relief of obstruction can be expected. Resolution of VUR in complex RALUR is lower than with primary, uncomplicated VUR, but comparable to published success of open megaureter repair. Robot-assisted laparoscopic surgery is a safe and effective approach for complex ureteral pathology, including megaureter, obstructed and refluxing duplex systems, and VUR with NGB.
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