- Email: [email protected]
Prospective Long-term Analysis of Nerve-sparing Extravesical Robotic-assisted Laparoscopic Ureteral Reimplantation
Pediatric Urology Prospective Long-term Analysis of Nervesparing Extravesical Robotic-assisted Laparoscopic Ureteral Reimplantation Sanjay Kasturi, Shailen S. Sehgal, Matthew S. Christman, Sarah M. Lambert, and Pasquale Casale OBJECTIVE
METHODS
RESULTS
CONCLUSION
To prospectively review our experience with extravesical robotic-assisted laparoscopic ureteral reimplantation to determine whether postoperative voiding dysfunction can be avoided with pelvic plexus visualization and to assess the efficacy of this approach for the treatment of vesicoureteral reflux (VUR). We prospectively followed 150 patients who underwent bilateral extravesical robotic-assisted laparoscopic ureteral reimplantation by a single surgeon at an academic institution. Each patient was followed for a 2-year period. All 150 patients had primary VUR of grade 3 or greater bilaterally, with 127 having parenchymal defects found on renal scans. All patients were toilet trained before surgical intervention. The operation was performed with an extravesical transperitoneal approach with robotic assistance using the daVinci Surgical System. All patients underwent voiding cystourethrography at 3 months postoperatively to document the resolution of VUR. Voiding dysfunction was assessed in each patient by uroflow, postvoid residual urine volume, and a validated questionnaire. The operative success rate was 99.3% for VUR resolution on voiding cystourethrography. One patient with bilateral grade 5 VUR that was downgraded to unilateral grade 2 VUR was considered to have treatment failure. This patient ultimately underwent subsequent subureteral injection therapy after an episode of pyelonephritis. No patient experienced de novo voiding dysfunction. Bilateral nerve-sparing robotic-assisted extravesical reimplantation has the same success rate as the traditional open approaches, with minimal morbidity and no voiding complications in our series. UROLOGY 79: 680 – 683, 2012. © 2012 Elsevier Inc.
U
rinary tract infection occurs in 2%-8% of children by 10 years of age.1 Vesicoureteral reflux (VUR) is present in approximately 30% of children who present with ⱖ1 urinary tract infection.2 Accepted clinical data have demonstrated that urinary tract infection in the presence of VUR can result in acute pyelonephritis and renal scarring.3,4 The treatment modalities for VUR vary and depend on a combination of clinical characteristics, including the severity of VUR, the presence of infection, and renal function. Currently, no consensus has been reached among healthcare professionals regarding when and how medical or surgical therapy should be used.5 Most patients are given long-term antibiotic prophylaxis until
From the Department of Surgery, Division of Urology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and Department of Surgery, Division of Urology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania Reprint requests: Pasquale Casale, M.D., Department of Surgery, Division of Urology, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Wood Building, Third Floor, Philadelphia, PA 19104. E-mail: [email protected] Submitted: August 8, 2011, accepted (with revisions): October 25, 2011
680
© 2012 Elsevier Inc. All Rights Reserved
VUR spontaneously resolves, the patient achieves excellent toilet habits and an absence of infection, or surgical correction is performed. Open ureteral reimplantation has been the reference standard surgical intervention.6 Subureteral injection of implant material has been used in recent years, with success rates approaching open surgery after ⱖ2 injections according to published series.7 During the past decade, both laparoscopic and roboticassisted laparoscopic techniques have been described for both intravesical and extravesical approaches.8-14 Overall, the operative success rates with laparoscopic approaches are comparable to their open counterparts. However, minimally invasive approaches are not without disadvantages. Laparoscopic extravesical reimplantation can potentially cause de novo voiding dysfunction in ⱕ10% of patients.13 Significant transient postoperative retention has been observed by others after extravesical robotic-assisted laparoscopic ureteral reimplantation (RALUR).15 Laparoscopic intravesical reimplantation is technically demanding and limited by the small capacity 0090-4295/12/$36.00 doi:10.1016/j.urology.2011.10.052
bladders.10 Nevertheless, advances in minimally invasive surgery for VUR have continued to be developed. Our group previously reported a 97.6% success rate in 41 patients treated with nerve-sparing extravesical RALUR with no associated complications. Additionally, we found no episodes of urinary retention owing to the visualization of the pelvic plexus afforded by robotic optics.14 Reviewer criticism emphasized that a larger prospective cohort with objective criteria was warranted to elucidate definitive conclusions regarding a robotic-assisted approach to ureteral reimplantation. Our prospective cohort was followed to determine whether a roboticassisted laparoscopic extravesical approach to ureteral reimplantation was efficacious and decreased the incidence of postoperative voiding complications.
MATERIAL AND METHODS We prospectively followed up 150 patients who underwent extravesical RALUR by a single surgeon at an academic institution. Each patient was followed for a 2-year period. All 150 patients had primary VUR of grade 3 or greater bilaterally. All the patients were evaluated with dimercaptosuccinic acid scans preoperatively. All 150 patients were toilet trained before surgical intervention. The operation was performed by a transperitoneal approach with robotic assistance using the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA). All patients in the present series were toilet trained and had been evaluated for voiding dysfunction with voiding diaries, uroflow studies, and postvoid residual urine volume measurements if the voiding habits were worrisome before surgical intervention. Biofeedback was used if necessary. Constipation was treated with stool regimens and confirmed with diaries, Bristol Stool Scales, and abdominal radiographs. Furthermore, the preoperative and 3-month postoperative Dysfunctional Outpatient Voiding Evaluation (DOVE) scores were obtained to assess voiding dysfunction, including nocturnal enuresis. The DOVE score is based on the Pediatric Lower Urinary Symptom Score, a 14-item measure with scores ranging from 0 to 35, with a score of 8.5 considered clinically significant.16,17 An additional quality of life item assesses the effect of urinary symptoms on family, social, and school life. Statistical analysis of the preoperative and postoperative DOVE scores was performed using a paired t test. Our RALUR begins with cystoscopy and placement of bilateral ureteral catheters and a urethral catheter. A transperitoneal approach was performed as previously described, with identification of the pelvic plexus to avoid injury to the area and allowing ureteral mobilization at the hiatus. This dissection is demonstrated in Figure 1. The operative time, length of stay, complications (Clavien classification18), postoperative urinary retention documented by uroflow and postvoid residual urine volume bladder scan, and postoperative resolution of VUR on a 3-month voiding cystourethrogram (VCUG) were documented for each patient.
RESULTS Patient age ranged from 27 to 111 months (mean 42.6). Of the 150 patients, 109 were girls and 41 were boys; 19 had bilateral grade 3, 35 bilateral grade 4, 17 bilateral UROLOGY 79 (3), 2012
Figure 1. Nerve-sparing extravesical RALUR dissection. Pelvic plexus lies medial and posterior to ureter and is exposed once ureter has been mobilized and retracted medially.
grade 5, and 79 had bilateral VUR with a combination of grades of 3-5 with or without duplication anomalies. Of the 79 patients, 3 had undergone previous incisions of ureteroceles as infants. Of the 150 patients, 12 had undergone previous Deflux (Q-Med Scandinavia, Princeton, NJ) injections. All the patients with previous Deflux injections had breakthrough pyelonephritis, and the families opted for reimplantation despite the option of a subsequent course of injection therapy. Of the 150 patients, 69 (46%) had febrile urinary tract infections during antibiotic prophylaxis; 55 (36%) had reflux that did not resolve with dimercaptosuccinic acid defects without breakthrough infections during prophylaxis; and the parents of 26 (18%) elected reimplantation because the reflux had not resolved after toilet training with negative dimercaptosuccinic acid scan findings. All the patients underwent cystoscopic evaluation and open-ended ureteral catheter placement at reimplantation. The mean operative time was 1.8 hours (range 1.1-3.2), including cystoscopy. The average length of stay was 22.1 hours (range 18-34). All urethral and ureteral catheters were removed the next postoperative day. All patients voided spontaneously after urethral catheter removal. No complications were noted. All the patients underwent postoperative ultrasonography at 3, 12, and 24 months after surgery. Postoperative VCUGs were performed after 3 months for all patients, with a VUR resolution rate of 99.3% (149 of 150). The 1 patient in whom RALUR failed presented with another episode of pyelonephritis before their scheduled VCUG date. This patient had had bilateral grade 5 VUR that was downgraded to unilateral grade 2. This patient underwent subsequent injection therapy of Deflux, with resolution of reflux documented 3 months after injection by VCUG. All patients were removed from prophylactic antibiotics after their negative studies. Regarding postoperative bladder dysfunction, all the patients underwent bladder scanning after voiding as an 681
inpatient after catheter removal. The postvoid residual urine volume averaged 3.2% (range 0%-11%) of the expected bladder capacity. All the patients underwent uroflow measurements and postvoid bladder scans at their subsequent 3-month outpatient visits before the VCUG. The mean average flow rate was 14.6 mL/s (range 8.928.6), with an average postvoid residual urine volume of 3.8% (range 0%-13%). These values were not significantly different from those at the preoperative assessment. Additionally, the mean preoperative and postoperative DOVE score was 3.96 and 3.66, respectively, and were not significantly different (P ⫽ .98).
COMMENT Laparoscopic ureteral reimplantation represents a new surgical approach to a classic operation. As such, the techniques for laparoscopic ureteral reimplantation and RALUR are still developing. These procedures are technically demanding, even for experienced laparoscopic and robotic surgeons. In the present prospective report of a large cohort of patients (n ⫽ 150), nerve-sparing extravesical RALUR was an efficacious procedure to correct VUR and demonstrated durable results at 2 years. Additionally, patients did not experience de novo voiding dysfunction, as measured by objective voiding parameters and a validated questionnaire. In our experience, visualization of the pelvic plexus is essential to preventing urinary retention. This technique involves retraction of the ureter medially, while the tissue medial and caudal to the ureter is retracted lateral and anterior to expose the nerves from the pelvic plexus to visualize the nerves entering distal to the ureteral hiatus into the trigone.14 This robotic technique allows the aforementioned dissection with minimal nerve disruption. Even in patients with a history of treated dysfunctional voiding, no postoperative urinary retention or exacerbation of dysfunctional voiding developed. The enhanced robotic visualization allows the detection and careful manipulation of the periureteral tissue at the bladder hiatus, allowing delineation of the pelvic plexus. In summary, although preoperative identification and treatment of voiding dysfunction and limited detrusor dissection are important, visualization of the pelvic plexus is paramount in preventing postoperative urinary retention. The benefits of RALUR reflected in the present series included a high success rate, a minimal length of stay (average 22.1 hours, range 18-34), the lack of postoperative voiding complications, and the absence of any adverse events. However, as our experience continued after completion of the present series, we did experience 1 Clavien grade IIIb complication after RALUR. One patient developed an intra-abdominal urinary leak requiring drainage with a Foley catheter for 5 days and bilateral pigtail stents for 2 months. She had anorexia on postoperative day 1 but tolerated oral fluids. She was discharged home and started to vomit on postoperative day 2. She returned to the emergency room for evalua682
tion, and urine was found in the abdomen requiring urinary diversion. In our experience of ⬎1000 minimally invasive cases, children progress rapidly to a normal state postoperatively, typically within 2-3 days. If any constitutional setbacks occur or increased discomfort develops, the patients must be evaluated for underlying pathologic features. Recently, 2 investigators have published their results comparing RALUR and open reimplantation.15,19 Smith et al15 retrospectively reviewed 2 cohorts of 25 patients; 1 cohort underwent extravesical RALUR and 1 open cross-trigonal repair. The overall success rate was 97% and 100% for the robotic and open group, respectively, after 16 months of follow-up. Although the operative time was longer for the RALUR cohort (3.1 vs 2.6 hours, P ⬍ .01), the patients treated with this modality benefited from a shorter hospital stay (33 vs 53 hours, P ⬍ .001) and lower analgesia requirements. However, the investigators found that after RALUR, 16% of the patients (most had undergone bilateral repairs) experienced transient postoperative urinary retention. Another retrospective study by Marchini et al19 examined 4 cohorts of patients: intravesical open reimplantation (n ⫽ 22), intravesical RALUR (n ⫽ 19), extravesical open reimplantation (n ⫽ 17), and extravesical RALUR (n ⫽ 20). The mean follow-up period ranged from 12 to 19 months. The overall success rates were equivalent between the RALUR and open groups (92%-100%). In the intravesical group, those undergoing RALUR benefited from a statistically significant shorter length of stay (43.2 vs 69.6 hours), shorter urethral catheter drainage duration (1.8 vs 2.9 days), and fewer bladder spasms than their open counterparts. However, no such differences were found between patients in the 2 arms of the extravesical group (length of stay 1.7 days for both). Although not statistically significant compared with the open cohorts, urinary retention did occur in 1 of the 19 patients in the intravesical RALUR cohort and 2 of the 20 patients in the extravesical RALUR group. The robotic-assisted laparoscopic procedures were longer than their open equivalents (intravesical open: 2.5 hours; RALUR: 3.9 hours; extravesical open: 2 hours; and RALUR: 3.9 hours). Although limited by their relatively small sizes and retrospective natures, these reports are encouraging for the acceptance of minimally invasive surgical approaches for ureteral reimplantation.
CONCLUSIONS Nerve-sparing extravesical RALUR has the same success rate as open approaches, with minimal morbidity in our series. We believe that visualization of the pelvic plexus is paramount to help avoid bladder dysfunction after surgery. Nerve-sparing extravesical RALUR should be regarded as a safe and equally effective modality as open approaches for reflux surgery. UROLOGY 79 (3), 2012
References 1. Winberg J, Andersen HJ, Bergstrom T, et al. Epidemiology of symptomatic urinary tract infection in childhood. Acta Paediatr Scand Suppl. 1974;257:1-20. 2. Stansfeld JM. Clinical observations relating to incidence and aetiology of urinary-tract infections in children. BMJ. 1966;1:631-635. 3. Risdon RA, Godley ML, Parkhouse HF, et al. Renal pathology and the 99mTc-DMSA image during the evolution of the early pyelonephritic scar: an experimental study. J Urol. 1994;151:767-773. 4. Rolleston GL, Shannon FT, Utley WL. Relationship of infantile vesicoureteric reflux to renal damage. BMJ. 1970;1:460-463. 5. Elder JS. Guidelines for consideration for surgical repair of vesicoureteral reflux. Curr Opin Urol. 2000;10:579-585. 6. Paquin AJ Jr. Ureterovesical anastomosis: the description and evaluation of a technique. J Urol. 1959;82:573-583. 7. Puri P, Chertin B, Velayudham M, et al. Treatment of vesicoureteral reflux by endoscopic injection of dextranomer/hyaluronic acid copolymer: preliminary results. J Urol. 2003;170:15411544. 8. Yeung CK, Sihoe JD, Borzi PA. Endoscopic cross-trigonal ureteral reimplantation under carbon dioxide bladder insufflation: a novel technique. J Endourol. 2005;19:295-299. 9. Peters CA, Woo R. Intravesical robotically assisted bilateral ureteral reimplantation. J Endourol. 2005;19:618-622. 10. Kutikov A, Guzzo TJ, Canter DJ, et al. Initial experience with laparoscopic transvesical ureteral reimplantation at the Children’s Hospital of Philadelphia. J Urol. 2006;176:2222-2226.
UROLOGY 79 (3), 2012
11. Canon SJ, Jayanthi VR, Patel AS. Vesicoscopic cross-trigonal ureteral reimplantation: a minimally invasive option for repair of vesicoureteral reflux. J Urol. 2007;178:269-273. 12. Valla JS, Steyaert H, Griffin SJ, et al. Transvesicoscopic Cohen ureteric reimplantation for vesicoureteral reflux in children: a single-centre 5-year experience. J Pediatr Urol. 2009;5:466-471. 13. Lakshmanan Y, Fung LC. Laparoscopic extravesicular ureteral reimplantation for vesicoureteral reflux: recent technical advances. J Endourol. 2000;14:589-594. 14. Casale P, Patel RP, Kolon TF. Nerve sparing robotic extravesical ureteral reimplantation. J Urol. 2008;179:1987-1990. 15. Smith RP, Oliver JL, Peters CA. Pediatric robotic extravesical ureteral reimplantation: comparison with open surgery. J Urol. 2011;185:1876-1881. 16. Schast AP, Zderic SA, Richter M, et al. Quantifying demographic, urological and behavioral characteristics of children with lower urinary tract symptoms. J Pediatr Urol. 2008;4:127-133. 17. Akbal C, Genc Y, Burgu B, et al. Dysfunctional voiding and incontinence scoring system: quantitative evaluation of incontinence symptoms in pediatric population. J Urol. 2005;173:969-973. 18. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205-213. 19. Marchini GS, Hong YK, Minnillo BJ, et al. Robotic assisted laparoscopic ureteral reimplantation in children: case matched comparative study with open surgical approach. J Urol. 2011;185:18701875.
683
METHODS
RESULTS
CONCLUSION
To prospectively review our experience with extravesical robotic-assisted laparoscopic ureteral reimplantation to determine whether postoperative voiding dysfunction can be avoided with pelvic plexus visualization and to assess the efficacy of this approach for the treatment of vesicoureteral reflux (VUR). We prospectively followed 150 patients who underwent bilateral extravesical robotic-assisted laparoscopic ureteral reimplantation by a single surgeon at an academic institution. Each patient was followed for a 2-year period. All 150 patients had primary VUR of grade 3 or greater bilaterally, with 127 having parenchymal defects found on renal scans. All patients were toilet trained before surgical intervention. The operation was performed with an extravesical transperitoneal approach with robotic assistance using the daVinci Surgical System. All patients underwent voiding cystourethrography at 3 months postoperatively to document the resolution of VUR. Voiding dysfunction was assessed in each patient by uroflow, postvoid residual urine volume, and a validated questionnaire. The operative success rate was 99.3% for VUR resolution on voiding cystourethrography. One patient with bilateral grade 5 VUR that was downgraded to unilateral grade 2 VUR was considered to have treatment failure. This patient ultimately underwent subsequent subureteral injection therapy after an episode of pyelonephritis. No patient experienced de novo voiding dysfunction. Bilateral nerve-sparing robotic-assisted extravesical reimplantation has the same success rate as the traditional open approaches, with minimal morbidity and no voiding complications in our series. UROLOGY 79: 680 – 683, 2012. © 2012 Elsevier Inc.
U
rinary tract infection occurs in 2%-8% of children by 10 years of age.1 Vesicoureteral reflux (VUR) is present in approximately 30% of children who present with ⱖ1 urinary tract infection.2 Accepted clinical data have demonstrated that urinary tract infection in the presence of VUR can result in acute pyelonephritis and renal scarring.3,4 The treatment modalities for VUR vary and depend on a combination of clinical characteristics, including the severity of VUR, the presence of infection, and renal function. Currently, no consensus has been reached among healthcare professionals regarding when and how medical or surgical therapy should be used.5 Most patients are given long-term antibiotic prophylaxis until
From the Department of Surgery, Division of Urology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and Department of Surgery, Division of Urology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania Reprint requests: Pasquale Casale, M.D., Department of Surgery, Division of Urology, Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Wood Building, Third Floor, Philadelphia, PA 19104. E-mail: [email protected] Submitted: August 8, 2011, accepted (with revisions): October 25, 2011
680
© 2012 Elsevier Inc. All Rights Reserved
VUR spontaneously resolves, the patient achieves excellent toilet habits and an absence of infection, or surgical correction is performed. Open ureteral reimplantation has been the reference standard surgical intervention.6 Subureteral injection of implant material has been used in recent years, with success rates approaching open surgery after ⱖ2 injections according to published series.7 During the past decade, both laparoscopic and roboticassisted laparoscopic techniques have been described for both intravesical and extravesical approaches.8-14 Overall, the operative success rates with laparoscopic approaches are comparable to their open counterparts. However, minimally invasive approaches are not without disadvantages. Laparoscopic extravesical reimplantation can potentially cause de novo voiding dysfunction in ⱕ10% of patients.13 Significant transient postoperative retention has been observed by others after extravesical robotic-assisted laparoscopic ureteral reimplantation (RALUR).15 Laparoscopic intravesical reimplantation is technically demanding and limited by the small capacity 0090-4295/12/$36.00 doi:10.1016/j.urology.2011.10.052
bladders.10 Nevertheless, advances in minimally invasive surgery for VUR have continued to be developed. Our group previously reported a 97.6% success rate in 41 patients treated with nerve-sparing extravesical RALUR with no associated complications. Additionally, we found no episodes of urinary retention owing to the visualization of the pelvic plexus afforded by robotic optics.14 Reviewer criticism emphasized that a larger prospective cohort with objective criteria was warranted to elucidate definitive conclusions regarding a robotic-assisted approach to ureteral reimplantation. Our prospective cohort was followed to determine whether a roboticassisted laparoscopic extravesical approach to ureteral reimplantation was efficacious and decreased the incidence of postoperative voiding complications.
MATERIAL AND METHODS We prospectively followed up 150 patients who underwent extravesical RALUR by a single surgeon at an academic institution. Each patient was followed for a 2-year period. All 150 patients had primary VUR of grade 3 or greater bilaterally. All the patients were evaluated with dimercaptosuccinic acid scans preoperatively. All 150 patients were toilet trained before surgical intervention. The operation was performed by a transperitoneal approach with robotic assistance using the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA). All patients in the present series were toilet trained and had been evaluated for voiding dysfunction with voiding diaries, uroflow studies, and postvoid residual urine volume measurements if the voiding habits were worrisome before surgical intervention. Biofeedback was used if necessary. Constipation was treated with stool regimens and confirmed with diaries, Bristol Stool Scales, and abdominal radiographs. Furthermore, the preoperative and 3-month postoperative Dysfunctional Outpatient Voiding Evaluation (DOVE) scores were obtained to assess voiding dysfunction, including nocturnal enuresis. The DOVE score is based on the Pediatric Lower Urinary Symptom Score, a 14-item measure with scores ranging from 0 to 35, with a score of 8.5 considered clinically significant.16,17 An additional quality of life item assesses the effect of urinary symptoms on family, social, and school life. Statistical analysis of the preoperative and postoperative DOVE scores was performed using a paired t test. Our RALUR begins with cystoscopy and placement of bilateral ureteral catheters and a urethral catheter. A transperitoneal approach was performed as previously described, with identification of the pelvic plexus to avoid injury to the area and allowing ureteral mobilization at the hiatus. This dissection is demonstrated in Figure 1. The operative time, length of stay, complications (Clavien classification18), postoperative urinary retention documented by uroflow and postvoid residual urine volume bladder scan, and postoperative resolution of VUR on a 3-month voiding cystourethrogram (VCUG) were documented for each patient.
RESULTS Patient age ranged from 27 to 111 months (mean 42.6). Of the 150 patients, 109 were girls and 41 were boys; 19 had bilateral grade 3, 35 bilateral grade 4, 17 bilateral UROLOGY 79 (3), 2012
Figure 1. Nerve-sparing extravesical RALUR dissection. Pelvic plexus lies medial and posterior to ureter and is exposed once ureter has been mobilized and retracted medially.
grade 5, and 79 had bilateral VUR with a combination of grades of 3-5 with or without duplication anomalies. Of the 79 patients, 3 had undergone previous incisions of ureteroceles as infants. Of the 150 patients, 12 had undergone previous Deflux (Q-Med Scandinavia, Princeton, NJ) injections. All the patients with previous Deflux injections had breakthrough pyelonephritis, and the families opted for reimplantation despite the option of a subsequent course of injection therapy. Of the 150 patients, 69 (46%) had febrile urinary tract infections during antibiotic prophylaxis; 55 (36%) had reflux that did not resolve with dimercaptosuccinic acid defects without breakthrough infections during prophylaxis; and the parents of 26 (18%) elected reimplantation because the reflux had not resolved after toilet training with negative dimercaptosuccinic acid scan findings. All the patients underwent cystoscopic evaluation and open-ended ureteral catheter placement at reimplantation. The mean operative time was 1.8 hours (range 1.1-3.2), including cystoscopy. The average length of stay was 22.1 hours (range 18-34). All urethral and ureteral catheters were removed the next postoperative day. All patients voided spontaneously after urethral catheter removal. No complications were noted. All the patients underwent postoperative ultrasonography at 3, 12, and 24 months after surgery. Postoperative VCUGs were performed after 3 months for all patients, with a VUR resolution rate of 99.3% (149 of 150). The 1 patient in whom RALUR failed presented with another episode of pyelonephritis before their scheduled VCUG date. This patient had had bilateral grade 5 VUR that was downgraded to unilateral grade 2. This patient underwent subsequent injection therapy of Deflux, with resolution of reflux documented 3 months after injection by VCUG. All patients were removed from prophylactic antibiotics after their negative studies. Regarding postoperative bladder dysfunction, all the patients underwent bladder scanning after voiding as an 681
inpatient after catheter removal. The postvoid residual urine volume averaged 3.2% (range 0%-11%) of the expected bladder capacity. All the patients underwent uroflow measurements and postvoid bladder scans at their subsequent 3-month outpatient visits before the VCUG. The mean average flow rate was 14.6 mL/s (range 8.928.6), with an average postvoid residual urine volume of 3.8% (range 0%-13%). These values were not significantly different from those at the preoperative assessment. Additionally, the mean preoperative and postoperative DOVE score was 3.96 and 3.66, respectively, and were not significantly different (P ⫽ .98).
COMMENT Laparoscopic ureteral reimplantation represents a new surgical approach to a classic operation. As such, the techniques for laparoscopic ureteral reimplantation and RALUR are still developing. These procedures are technically demanding, even for experienced laparoscopic and robotic surgeons. In the present prospective report of a large cohort of patients (n ⫽ 150), nerve-sparing extravesical RALUR was an efficacious procedure to correct VUR and demonstrated durable results at 2 years. Additionally, patients did not experience de novo voiding dysfunction, as measured by objective voiding parameters and a validated questionnaire. In our experience, visualization of the pelvic plexus is essential to preventing urinary retention. This technique involves retraction of the ureter medially, while the tissue medial and caudal to the ureter is retracted lateral and anterior to expose the nerves from the pelvic plexus to visualize the nerves entering distal to the ureteral hiatus into the trigone.14 This robotic technique allows the aforementioned dissection with minimal nerve disruption. Even in patients with a history of treated dysfunctional voiding, no postoperative urinary retention or exacerbation of dysfunctional voiding developed. The enhanced robotic visualization allows the detection and careful manipulation of the periureteral tissue at the bladder hiatus, allowing delineation of the pelvic plexus. In summary, although preoperative identification and treatment of voiding dysfunction and limited detrusor dissection are important, visualization of the pelvic plexus is paramount in preventing postoperative urinary retention. The benefits of RALUR reflected in the present series included a high success rate, a minimal length of stay (average 22.1 hours, range 18-34), the lack of postoperative voiding complications, and the absence of any adverse events. However, as our experience continued after completion of the present series, we did experience 1 Clavien grade IIIb complication after RALUR. One patient developed an intra-abdominal urinary leak requiring drainage with a Foley catheter for 5 days and bilateral pigtail stents for 2 months. She had anorexia on postoperative day 1 but tolerated oral fluids. She was discharged home and started to vomit on postoperative day 2. She returned to the emergency room for evalua682
tion, and urine was found in the abdomen requiring urinary diversion. In our experience of ⬎1000 minimally invasive cases, children progress rapidly to a normal state postoperatively, typically within 2-3 days. If any constitutional setbacks occur or increased discomfort develops, the patients must be evaluated for underlying pathologic features. Recently, 2 investigators have published their results comparing RALUR and open reimplantation.15,19 Smith et al15 retrospectively reviewed 2 cohorts of 25 patients; 1 cohort underwent extravesical RALUR and 1 open cross-trigonal repair. The overall success rate was 97% and 100% for the robotic and open group, respectively, after 16 months of follow-up. Although the operative time was longer for the RALUR cohort (3.1 vs 2.6 hours, P ⬍ .01), the patients treated with this modality benefited from a shorter hospital stay (33 vs 53 hours, P ⬍ .001) and lower analgesia requirements. However, the investigators found that after RALUR, 16% of the patients (most had undergone bilateral repairs) experienced transient postoperative urinary retention. Another retrospective study by Marchini et al19 examined 4 cohorts of patients: intravesical open reimplantation (n ⫽ 22), intravesical RALUR (n ⫽ 19), extravesical open reimplantation (n ⫽ 17), and extravesical RALUR (n ⫽ 20). The mean follow-up period ranged from 12 to 19 months. The overall success rates were equivalent between the RALUR and open groups (92%-100%). In the intravesical group, those undergoing RALUR benefited from a statistically significant shorter length of stay (43.2 vs 69.6 hours), shorter urethral catheter drainage duration (1.8 vs 2.9 days), and fewer bladder spasms than their open counterparts. However, no such differences were found between patients in the 2 arms of the extravesical group (length of stay 1.7 days for both). Although not statistically significant compared with the open cohorts, urinary retention did occur in 1 of the 19 patients in the intravesical RALUR cohort and 2 of the 20 patients in the extravesical RALUR group. The robotic-assisted laparoscopic procedures were longer than their open equivalents (intravesical open: 2.5 hours; RALUR: 3.9 hours; extravesical open: 2 hours; and RALUR: 3.9 hours). Although limited by their relatively small sizes and retrospective natures, these reports are encouraging for the acceptance of minimally invasive surgical approaches for ureteral reimplantation.
CONCLUSIONS Nerve-sparing extravesical RALUR has the same success rate as open approaches, with minimal morbidity in our series. We believe that visualization of the pelvic plexus is paramount to help avoid bladder dysfunction after surgery. Nerve-sparing extravesical RALUR should be regarded as a safe and equally effective modality as open approaches for reflux surgery. UROLOGY 79 (3), 2012
References 1. Winberg J, Andersen HJ, Bergstrom T, et al. Epidemiology of symptomatic urinary tract infection in childhood. Acta Paediatr Scand Suppl. 1974;257:1-20. 2. Stansfeld JM. Clinical observations relating to incidence and aetiology of urinary-tract infections in children. BMJ. 1966;1:631-635. 3. Risdon RA, Godley ML, Parkhouse HF, et al. Renal pathology and the 99mTc-DMSA image during the evolution of the early pyelonephritic scar: an experimental study. J Urol. 1994;151:767-773. 4. Rolleston GL, Shannon FT, Utley WL. Relationship of infantile vesicoureteric reflux to renal damage. BMJ. 1970;1:460-463. 5. Elder JS. Guidelines for consideration for surgical repair of vesicoureteral reflux. Curr Opin Urol. 2000;10:579-585. 6. Paquin AJ Jr. Ureterovesical anastomosis: the description and evaluation of a technique. J Urol. 1959;82:573-583. 7. Puri P, Chertin B, Velayudham M, et al. Treatment of vesicoureteral reflux by endoscopic injection of dextranomer/hyaluronic acid copolymer: preliminary results. J Urol. 2003;170:15411544. 8. Yeung CK, Sihoe JD, Borzi PA. Endoscopic cross-trigonal ureteral reimplantation under carbon dioxide bladder insufflation: a novel technique. J Endourol. 2005;19:295-299. 9. Peters CA, Woo R. Intravesical robotically assisted bilateral ureteral reimplantation. J Endourol. 2005;19:618-622. 10. Kutikov A, Guzzo TJ, Canter DJ, et al. Initial experience with laparoscopic transvesical ureteral reimplantation at the Children’s Hospital of Philadelphia. J Urol. 2006;176:2222-2226.
UROLOGY 79 (3), 2012
11. Canon SJ, Jayanthi VR, Patel AS. Vesicoscopic cross-trigonal ureteral reimplantation: a minimally invasive option for repair of vesicoureteral reflux. J Urol. 2007;178:269-273. 12. Valla JS, Steyaert H, Griffin SJ, et al. Transvesicoscopic Cohen ureteric reimplantation for vesicoureteral reflux in children: a single-centre 5-year experience. J Pediatr Urol. 2009;5:466-471. 13. Lakshmanan Y, Fung LC. Laparoscopic extravesicular ureteral reimplantation for vesicoureteral reflux: recent technical advances. J Endourol. 2000;14:589-594. 14. Casale P, Patel RP, Kolon TF. Nerve sparing robotic extravesical ureteral reimplantation. J Urol. 2008;179:1987-1990. 15. Smith RP, Oliver JL, Peters CA. Pediatric robotic extravesical ureteral reimplantation: comparison with open surgery. J Urol. 2011;185:1876-1881. 16. Schast AP, Zderic SA, Richter M, et al. Quantifying demographic, urological and behavioral characteristics of children with lower urinary tract symptoms. J Pediatr Urol. 2008;4:127-133. 17. Akbal C, Genc Y, Burgu B, et al. Dysfunctional voiding and incontinence scoring system: quantitative evaluation of incontinence symptoms in pediatric population. J Urol. 2005;173:969-973. 18. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205-213. 19. Marchini GS, Hong YK, Minnillo BJ, et al. Robotic assisted laparoscopic ureteral reimplantation in children: case matched comparative study with open surgical approach. J Urol. 2011;185:18701875.
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