LAPAROSCOPIC CROSS-TRIGONAL COHEN URETERONEOCYSTOSTOMY: NOVEL TECHNIQUE

0022-5347/01/1665-1811/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®

Vol. 166, 1811–1814, November 2001 Printed in U.S.A.

Urologists at Work LAPAROSCOPIC CROSS-TRIGONAL COHEN URETERONEOCYSTOSTOMY: NOVEL TECHNIQUE INDERBIR S. GILL, LEE E. PONSKY, MAHESH DESAI, ROBERT KAY

AND

JONATHAN H. ROSS

From the Sections of Laparoscopic and Minimally Invasive Surgery and Pediatric Urology, Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio

ABSTRACT

Purpose: We describe a novel technique of laparoscopic transvesical cross-trigonal Cohen anti-reflux ureteroneocystostomy. Materials and Methods: A 10, an 11 and a 32-year-old patient with symptomatic unilateral vesicoureteral reflux underwent laparoscopic cross-trigonal ureteral reimplantation. Two 5 mm. balloon tip ports were suprapubically inserted into the bladder. Using a transurethral resectoscope with a Collins knife a 4 to 5 cm. cross-trigonal submucosal trough was created from the refluxing ureteral orifice to the contralateral side of the bladder. The refluxing ureteral orifice and intramural ureter were completely mobilized intravesically, advanced transtrigonally and secured to the detrusor muscle at the apex of the trough with 3 deep interrupted sutures. The elevated mucosal flaps of the trough were suture approximated over the ureter to create a submucosal tunnel. All suturing was performed by freehand laparoscopic technique. Results: Operative time was between 2.5 and 4.5 hours and blood loss was 10 to 50 cc. Adequate submucosal trough creation, ureteral extravesical mobilization and intravesical advancement, and bladder mucosal flap reapproximation were done to create a submucosal tunnel in all cases. Satisfactory transtrigonal anchoring of the neoureteral orifice to the detrusor muscle and mucosa was achieved with 3 stitches. Hospital stay was 2, 2 and 1 days in the 3 cases, and the Foley catheter remained in place for 3, 1 and 1 week, respectively. At 6 months reflux had resolved in 2 patients, while in 1 grade II reflux persisted, which was improved from grade IV preoperatively. All patients have remained infection-free without antibiotics. Conclusions: Laparoscopic transvesical cross-trigonal antireflux ureteral reimplantation is technically feasible. Intravesical laparoscopic suturing is possible. Potential advantages include a decreased hospital stay, decreased narcotic requirement and better cosmesis. Further experience is necessary to refine the technical nuances and evaluate outcomes compared to the open technique. KEY WORDS: ureter, laparoscopy, vesico-ureteral reflux

Previously described minimally invasive techniques for treating vesicoureteral reflux include cystoscopic subtrigonal injection of bulking agents1–3 and laparoscopic extravesical reimplantation.4 – 6 The former has a significant 17% to 91% long-term failure rate1, 2 and the latter has the potential disadvantages of postoperative voiding dysfunction as well as the complications of the transperitoneal approach. Cartwright et al described a method of combining laparoscopic and endoscopic techniques to perform ureteral advancement, as previously described in open fashion by GilVernet,7 with uncertain results.8 The open surgical Cohen cross-trigonal reimplantation technique is uniformly associated with good results and it is the preferred technique at our institution. We recently described a transvesical laparoscopic technique for mobilizing the distal ureter and bladder cuff during laparoscopic radical nephroureterectomy.9 We extended and further developed this technique to perform Cohen cross-trigonal ureteroneocystostomy and report our initial experience. Accepted for publication June 15, 2001.

MATERIALS AND METHODS

Two females and 1 male 10, 11 and 32 years old with grades III, II and IV vesicoureteral reflux, respectively, had a breakthrough urinary tract infection during conservative treatment with prophylactic antibiotics. Various management options were offered and the patients elected laparoscopic Cohen reimplantation. Informed consent was obtained. The patient was placed in the modified lithotomy position with abducted thighs, and the abdomen and genitalia were prepared and draped in sterile fashion. Cystoscopy was performed with a 30-degree lens and glycine irrigation. A Double-J stent (Medical Engineering Corp., New York, New York) was placed into the targeted ureter and renal pelvis. Under cystoscopic guidance 2, 5 mm. balloon tip ports were suprapubically inserted into the completely distended bladder 1 finger breadth superior to the symphysis pubis with 1 each on either side of the midline (part A of figure). The balloon of each port was inflated with 8 cc air and the external cuff was cinched down to secure the port tip within the

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Laparoscopic right ureteral reimplantation. A, proposed site of 4 to 5 cm. cross-trigonal submucosal tunnel is scored on bladder base mucosa with electrocautery using transurethral resectoscope mounted with electrosurgical Collins knife. B, mucosal flaps of proposed submucosal tunnel are developed cranial and caudal from scored line on vesical mucosa using 5 mm. instruments inserted through 2 suprapubic trocars. C, mucosal flap elevation is complete and bed of cross-trigonal submucosal tunnel is created. Right ureter is detached circumferentially from full-thickness bladder wall and mobilized extravesically for 2 to 3 cm. (arrow). This extravesical dissection remains in pelvic extraperitoneal space. D, mobilized ureter is advanced transtrigonally and neoureteral orifice is anchored to detrusor muscle and mucosa with 3 deep interrupted stitches using freehand laparoscopic technique. E, mucosal flaps are reapproximated over ureter with 3 to 4 interrupted stitches to complete anti-reflux submucosal tunnel.

bladder in watertight fashion. The 2 ports were attached to continuous wall suction. The cystoscope was replaced by a 24Fr resectoscope loaded with an electrosurgical Collins knife. Visualization during the whole procedure was provided by the transurethral positioned endoscope with the fore oblique 30-degree lens and attached video camera. Using the Collins knife the direction and length (4 to 5 cm.) of the proposed cross-trigonal submucosal tunnel was scored on the bladder mucosa with electrocautery (part A of figure). Using suprapubically inserted, 5 mm. laparoscopic grasping forceps and 5 mm. electrosurgical scissors the bladder mucosa was elevated on either side of the previously scored marking to create a submucosal bed for the subsequent ureteral tunnel (part B of figure). The targeted ureteral orifice was grasped with the suprapubic grasper and elevated anterior, tenting up the ipsilateral hemitrigone. Using the resectoscope and Collins knife with care taken of the contralateral ureteral orifice the targeted ureteric orifice and

intramural ureter were circumferentially detached from the full-thickness bladder wall (part C of figure). The extravesical pelvic extraperitoneal fatty tissues were gently dissected bluntly off the ureter by the Collins knife, mobilizing 2 to 3 cm. of extravesical ureter into the bladder. Continuous wall suction on the 2 suprapubic ports maintained the bladder in a decompressed state, minimizing irrigating fluid extravasation. A 3-zero polyglactin suture on an RB-1 needle was inserted into the bladder through a suprapubic port. With a laparoscopic needle driver a deep stitch was passed through the detrusor muscle at the apex of the submucosal trough and subsequently through the posterior lip of the mobilized ureteral orifice. The needle was retrieved outside of the port and the knot was tied by the extracorporeal technique using a closed knot pusher or intravesically. A single additional stitch on either side of the primary stitch was placed in similar fashion, anchoring the neoureteral orifice securely to

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the detrusor at the desired location at the apex of the crosstrigonal submucosal bed (part D of figure). The posterior cystotomy at the original ureteral hiatus was narrowed with a stitch as necessary. The previously created mucosal flaps were then reapproximated over the ureter with 3 to 4 interrupted 4-zero polyglactin stitches to construct the submucosal tunnel (part E of figure). RESULTS

Operative time was between 2.5 and 4.5 hours (see table). Estimated blood loss was 10 to 50 cc. Adequate transtrigonal submucosal bed creation, mucosal flap elevation, ureteral extravesical mobilization and intravesical advancement, and bladder mucosal flap reapproximation to create a submucosal tunnel were feasible in all cases. The neoureteral orifice was anchored to the detrusor muscle and mucosa in satisfactory fashion with 3 stitches. Hospital stay was 2 days in patients 1 and 2, and 1 day in patient 3. The Foley catheter remained in place for 3 weeks in patient 1 and at 1 week in patients 2 and 3. A Double-J ureteral stent was left in place for 4 and 6 weeks in 2 cases. To ensure complete drainage of any perivesical extraperitoneal fluid extravasation a drain was suprapubically placed in the right perivesical space for 24 hours in patient 1. No drain was placed in the other 2 cases. All patients required oral analgesia for only 24 hours after discharge home. In patients 1 and 3 voiding cystourethrography and ultrasound were normal at 6 months with complete correction of reflux. In patient 2 grade II reflux persisted at 6 months, which was improved from grade IV preoperatively. During cystoscopic extraction of the Double J-stent at 4 weeks in this case the stent was noted to have migrated distal and it was somewhat excessively curved in the bladder, possibly leading to traction on and disruption of the mucosal flap stitches. All 3 patients were infection-free without antibiotics at the last followup. DISCUSSION

Previous attempts at laparoscopic ureteral reimplantation have involved the extravesical Lich-Gregoir technique with variable success.4, 5, 10, 11 Ehrlich et al,4 and Reddy and Evans6 independently showed the safety and feasibility of this technique clinically in 2 and 1 patients, respectively. In a recent series Lakshmanan and Fung reported 71 laparoscopic extravesical reimplantations, including 23 unilateral and 24 bilateral, with no persistent reflux or obstruction postoperatively.12 Although detailed data were not provided, they described an overall success rate comparable to that of open surgery. Voiding dysfunction has been noted in some patients after open extravesical reimplantation. Furthermore, laparoscopic extravesical reimplantation requires the transperitoneal approach. Various laparoscopic techniques have also been described for ureteral reimplantation into an ileal conduit and experimental ileal neobladder.13, 14 The procedure that we present duplicates in laparoscopic fashion the basic principles and maintains the advantages of a Cohen reimplantation, while using a purely transvesical and minimally invasive technique. In 1 case the procedure failed and reflux persisted, although it was improved. In this patient a Double-J stent remained in place for 4 weeks postoperatively. At cystoscopy

Patient data Pt. 1 Age Sex Reflux side/grade Operative time (hrs.) Wks. stented Results

11 F Rt./II 4.5 0 Success

Pt. 2

Pt. 3

32 M Lt./IV 3 6 Grade II reflux

10 F Rt./III 2.5 4 Success

for stent removal the distal 2 stitches in the mucosal flaps that created the submucosal tunnel had torn through the tissue. It is possible that the curl in the stent placed tension on the stitches used to close the mucosal flaps. It may also have been possible that there was inadequate mobilization of the ureter with tension foreshortening the intravesical segment. In addition, due to grade IV reflux and the patulous ureteral orifice in this patient circumferential detachment of the intramural ureter resulted in a somewhat larger hole in the detrusor muscle. No specific attempt was made to place a stitch to narrow this hole snugly around the advanced ureter. It is likely that the deficient detrusor backing in this area partially contributed to persistent but improved vesicoureteral reflux in this patient. Therefore, we recommend that the posterior cystotomy at the site of the original ureteric orifice should be narrowed by 1 to 2 stitches before reapproximating the mucosal flaps to create the submucosal tunnel. Also, in the future we intend to remove the Double-J stent immediately after completing intravesical reconstruction before terminating the procedure. Certain technical points are important. Constant wall suction should be maintained through the suprapubic ports to create low intravesical pressure for minimizing fluid extravasation. An adequate 4 to 5 cm. transtrigonal submucosal tunnel should be constructed. The mucosal flaps should be developed generously before ureteral detachment. The extravesical ureter should be mobilized sufficiently. The neoureteral orifice should be firmly anchored to the detrusor. The posterior cystotomy should be narrowed at the site of the original ureteral orifice as necessary. In addition, the mucosal flaps should be reapproximated to create an anti-reflux tunnel. Potential advantages include a short hospital stay, minimal bladder spasms, decreased analgesic requirement and superior cosmesis. We recognize certain limitations of this technique. Primarily a significant learning curve is involved due to the small working space within the bladder and need for intravesical laparoscopic freehand suturing. Although a Double-J stent was placed in 2 of our 3 patients, we do not believe that it is routinely necessary in the future. Since we did not achieve watertight closure of the posterior cystotomy at the original ureteral hiatus, 1 week of Foley catheterization was done to ensure complete intravesical healing under low pressure. This catheter duration was longer than that during open cross-trigonal reimplantation. However, we plan to approximate formally the posterior defect in future cases and, thus, decrease the catheter duration to be more in line with that of open surgery. This technique is probably not suitable for bilateral ureteral reimplantation. Furthermore, while crosstrigonal reimplantation remains our preferred approach, there may be concern that future retrograde ureteral access would be hindered. Our minimally invasive technique of cross-trigonal reimplantation would obviously be subject to this concern. However, each alternative approach has unique disadvantages. CONCLUSIONS

Our initial experience with this transvesical transtrigonal laparoscopic ureteral reimplantation technique is encouraging. To our knowledge this report represents the initial attempt at intracavitary freehand laparoscopic suturing and reconstruction within the bladder. Further experience is necessary to refine stenting and drainage issues, and compare the outcome with that of open surgery. REFERENCES

1. De Grazia, E. and Cimador, M.: Long-term follow-up results of vesico-ureteral reflux treated with subureteral collagen injection (SCIN). Minerva Pediatr, 52: 7, 2000 2. Haferkamp, A., Contractor, H., Mohring, K. et al: Failure of

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subureteral bovine collagen injection for the endoscopic treatment of primary vesicoureteral reflux in long-term follow-up. Urology, 55: 759, 2000 Ross, J. H. and Kay, R.: Pediatric urinary tract infection and reflux. Am Fam Physician, 59: 1472, 1999 Ehrlich, R. M., Gershman, A. and Fuchs, G.: Laparoscopic vesicoureteroplasty in children: initial case reports. Urology, 43: 255, 1994 Janetschek, G., Radmayr, C. and Bartsch, G.: Laparoscopic ureteral anti-reflux plasty reimplantation. First clinical experience. Ann Urol (Paris), 29: 101, 1995 Reddy, P. K. and Evans, R. M.: Laparoscopic ureteroneocystostomy. J Urol, 152: 2057, 1994 Gil-Vernet, J. M.: A new technique for surgical correction of vesicoureteral reflux. J Urol, 86: 554, 1961 Cartwright, P. C., Snow, B. W., Mansfield, J. C. et al: Percutaneous endoscopic trigonoplasty: a minimally invasive approach to correct vesicoureteral reflux. J Urol, part 2, 156: 661, 1996 Gill, I. S., Soble, J. J., Miller, S. D. et al: A novel technique for the management of the en bloc bladder cuff and distal ureter during laparoscopic nephroureterectomy. J Urol, 161: 430, 1999 Atala, A., Kavoussi, L. R., Goldstein, D. S. et al: Laparoscopic correction of vesicoureteral reflux. J Urol, part 2, 150: 748, 1993 McDougall, E. M., Urban, D. A., Kerbl, K. et al: Laparoscopic repair of vesicoureteral reflux utilizing the Lich-Gregoir technique in the pig model. J Urol, 153: 497, 1995 Lakshmanan, Y. and Fung, L. C.: Laparoscopic extravesicular ureteral reimplantation for vesicoureteral reflux: recent technical advances. J Endourol, 14: 589, 2000 Gill, I. S., Fergany, A., Klein, E. A. et al: Laparoscopic radical

cystoprostatectomy with ileal conduit performed completely intracorporeally: the initial 2 cases. Urology, 56: 26, 2000 14. Kaouk, J., Gill, I. S., Desai, M. M. et al: Laparoscopic orthotopic ileal neobladder. J Endourol, 15: 131, 2001 EDITORIAL COMMENT The authors report a novel approach for the endoscopic repair of vesicoureteral reflux. I would prefer that a term other than laparoscopic be used to describe the approach as the trocars are placed suprapubicly into the bladder under endoscopic control. It is true etymologically that laparoscopic refers to the abdominal wall but general usage typically infers a transperitoneal or retroperitoneal extravisceral approach. Using open techniques and ketoralac for postoperative analgesia, a success rate of 97% can be achieved with a 1-day hospital stay. Hence, unless the success rate is comparable, I see no advantage of this approach to open procedures. George W. Kaplan Pediatric Urological Associates San Diego, California REPLY BY AUTHORS By avoiding a standard surgical incision this approach offers the potential advantages of decreased operative time, decreased morbidity, an even shorter hospital stay and improved cosmesis. We agree that, given the relatively low morbidity of the current open approaches, the long-term success rate of any laparoscopic approach will have to be at least comparable. Since our approach attempts to recreate the standard open approach, we are optimistic that this can be achieved. However, our report is merely an initial feasibility study. Clearly, it will take a much larger experience to allow a true comparison.