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Robot-assisted laparoscopic megaureter tapering with ureteral reimplantation: Tips and tricks
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MODEL
Journal of Pediatric Urology (2017) xx, 1e2
Video Bank
Robot-assisted laparoscopic megaureter tapering with ureteral reimplantation: Tips and tricks a
Department of Urology, Loyola University Medical Center, Maywood, IL, USA
Belinda Li a, Bruce W. Lindgren b, Dennis B. Liu b, Edward M. Gong b Summary
b
Division of Urology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA Correspondence to: E.M. Gong, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Avenue, Box 24, Chicago, IL 60611, USA [email protected] (E.M. Gong) Keywords Megaureter tapering; Megaureter; Ureteral reimplantation; Robotics Received 13 January 2017 Accepted 6 September 2017 Available online xxx
Objective The aim was to demonstrate surgical techniques used in pediatric robot-assisted laparoscopic megaureter tapering (RALMT) with ureteral reimplantation. We report on our preliminary experience.
Results Between August 2012 and November 2015, 14 patients underwent RALMT with ureteral reimplantation. Highlighted techniques include variations in ureteral stent insertion, method of excisional tapering, and approach to reimplantation. All (10/ 10) patients with postoperative ultrasounds following ureteral stent removal demonstrated radiographic improvement at a mean follow-up of 9 months. No patients had postoperative febrile urinary tract infections. The only complication was one patient with postoperative ileus.
Methods We reviewed video of patients who underwent RALMT with ureteral reimplantation between August 2012 and November 2015. MT was performed extravesically and ureteral reimplantation was performed by extravesical detrusorrhaphy with ureteral anchoring. All patients had an intraoperatively placed ureteral stent.
Conclusions We demonstrate variations in surgical techniques which may facilitate the surgical steps of RALMT with ureteral reimplantation. Our preliminary experience suggests the procedure is safe and feasible for pediatric patients with symptomatic megaureter.
Introduction
Methods
Recent work reviewing trends in pediatric ureteral reimplantation shows a steady increase in robotic surgery between 2009 and 2012 [1]. With these rising trends and additional concerns about the safety and efficacy of this approach, it is important to review our techniques and outcomes to ensure delivery of optimal care [2]. We report our preliminary experience with pediatric robot-assisted laparoscopic megaureter tapering (RALMT) with ureteral reimplantation for both refluxing and obstructive megaureters, with attention to specific surgical techniques as demonstrated in the accompanying video.
Non-refluxing obstructive megaureter
Supplementary data related to this article can be found online at https://doi.org/10. 1016/j.jpurol.2017.09.013.
A double-J ureteral stent is inserted cystoscopically. Once the robot is docked, the distal ureter is mobilized. A series of interrupted stay sutures placed along the anterior ureteral wall allows for atraumatic manipulation during excisional tapering, which is performed before dismembering the ureter. This method provides traction to stabilize the ureter. Once ureteral reconstruction is complete, a bladder hitch stitch straightens the proposed detrusor tunnel preparing for ureteral reimplantation. The ureter is transected at the bladder mucosa after detrusor dissection and the obstructive segment is discarded. The ureteroneocystostomy is performed, ensuring the stent is passed into the bladder before completion. The detrusor tunnel is
https://doi.org/10.1016/j.jpurol.2017.09.013 1477-5131/ª 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Li B, et al., Robot-assisted laparoscopic megaureter tapering with ureteral reimplantation: Tips and tricks, Journal of Pediatric Urology (2017), https://doi.org/10.1016/j.jpurol.2017.09.013
+
MODEL
2 closed and the hitch stitch is released to confirm appropriate orientation of the ureter. If a stent cannot be placed cystoscopically due to either a stenotic ureterovesical junction or severe proximal tortuosity, an alternate method of excisional tapering and stent placement is effective. Once the distal ureter is mobilized, a hitch stitch is passed percutaneously through the ureter, which is anchored towards the abdominal wall. The ureter is then transected distal to the hitch stitch. With the transected ureter exposed, the ureteral stent is inserted percutaneously in a retrograde fashion. Excisional tapering is then performed and the ureter is reconstructed. The narrowed ureteral segment is excised at the bladder mucosa and the dismembered reimplantation proceeds.
Refluxing megaureter Excisional tapering of the ureter takes place as described above, however since dismembering is not required it is immediately followed by reimplantation.
Results Fourteen patients underwent RALMT with ureteral reimplantation between August 2012 and November 2015. The mean operative time was 276 min, including a bilateral case. Certain components of the procedure may be facilitated by variations in surgical technique, among which we have highlighted ureteral stent insertion, method of excisional tapering, and method of reimplantation. All (10/10) patients who completed postoperative ultrasounds after ureteral stent removal demonstrated radiographic improvement at a mean follow-up of 9 months and none of the patients had postoperative febrile urinary tract infections.
B. Li et al.
Conclusions RALMT with ureteral reimplantation is safe and feasible for treating pediatric obstructive and refluxing megaureters. Technical variations may assist with facilitating optimal surgical outcomes.
Conflict of interest B.W.L. Intuitive surgical: travel/accommodation for faculty role at Intuitive Master’s Course (instructional course). January 2016.
Funding None.
Ethical approval Institutional Review Board approval was obtained.
References [1] Bowen DK, Faasse MA, Liu DB, Gong EM, Lindgren BW, Johnson EK. Use of pediatric open, laparoscopic and robotassisted laparoscopic ureteral reimplantation in the United States: 2000 to 2012. J Urol 2016;196(1):207e12. [2] Grimsby GM, Dwyer ME, Jacobs MA, Ost MC, Schneck FX, Cannon GM, et al. Multi-institutional review of outcomes of robot-assisted laparoscopic extravesical ureteral reimplantation. J Urol 2015;193(5 Suppl.):1791e5.
Please cite this article in press as: Li B, et al., Robot-assisted laparoscopic megaureter tapering with ureteral reimplantation: Tips and tricks, Journal of Pediatric Urology (2017), https://doi.org/10.1016/j.jpurol.2017.09.013
MODEL
Journal of Pediatric Urology (2017) xx, 1e2
Video Bank
Robot-assisted laparoscopic megaureter tapering with ureteral reimplantation: Tips and tricks a
Department of Urology, Loyola University Medical Center, Maywood, IL, USA
Belinda Li a, Bruce W. Lindgren b, Dennis B. Liu b, Edward M. Gong b Summary
b
Division of Urology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA Correspondence to: E.M. Gong, Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Avenue, Box 24, Chicago, IL 60611, USA [email protected] (E.M. Gong) Keywords Megaureter tapering; Megaureter; Ureteral reimplantation; Robotics Received 13 January 2017 Accepted 6 September 2017 Available online xxx
Objective The aim was to demonstrate surgical techniques used in pediatric robot-assisted laparoscopic megaureter tapering (RALMT) with ureteral reimplantation. We report on our preliminary experience.
Results Between August 2012 and November 2015, 14 patients underwent RALMT with ureteral reimplantation. Highlighted techniques include variations in ureteral stent insertion, method of excisional tapering, and approach to reimplantation. All (10/ 10) patients with postoperative ultrasounds following ureteral stent removal demonstrated radiographic improvement at a mean follow-up of 9 months. No patients had postoperative febrile urinary tract infections. The only complication was one patient with postoperative ileus.
Methods We reviewed video of patients who underwent RALMT with ureteral reimplantation between August 2012 and November 2015. MT was performed extravesically and ureteral reimplantation was performed by extravesical detrusorrhaphy with ureteral anchoring. All patients had an intraoperatively placed ureteral stent.
Conclusions We demonstrate variations in surgical techniques which may facilitate the surgical steps of RALMT with ureteral reimplantation. Our preliminary experience suggests the procedure is safe and feasible for pediatric patients with symptomatic megaureter.
Introduction
Methods
Recent work reviewing trends in pediatric ureteral reimplantation shows a steady increase in robotic surgery between 2009 and 2012 [1]. With these rising trends and additional concerns about the safety and efficacy of this approach, it is important to review our techniques and outcomes to ensure delivery of optimal care [2]. We report our preliminary experience with pediatric robot-assisted laparoscopic megaureter tapering (RALMT) with ureteral reimplantation for both refluxing and obstructive megaureters, with attention to specific surgical techniques as demonstrated in the accompanying video.
Non-refluxing obstructive megaureter
Supplementary data related to this article can be found online at https://doi.org/10. 1016/j.jpurol.2017.09.013.
A double-J ureteral stent is inserted cystoscopically. Once the robot is docked, the distal ureter is mobilized. A series of interrupted stay sutures placed along the anterior ureteral wall allows for atraumatic manipulation during excisional tapering, which is performed before dismembering the ureter. This method provides traction to stabilize the ureter. Once ureteral reconstruction is complete, a bladder hitch stitch straightens the proposed detrusor tunnel preparing for ureteral reimplantation. The ureter is transected at the bladder mucosa after detrusor dissection and the obstructive segment is discarded. The ureteroneocystostomy is performed, ensuring the stent is passed into the bladder before completion. The detrusor tunnel is
https://doi.org/10.1016/j.jpurol.2017.09.013 1477-5131/ª 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Li B, et al., Robot-assisted laparoscopic megaureter tapering with ureteral reimplantation: Tips and tricks, Journal of Pediatric Urology (2017), https://doi.org/10.1016/j.jpurol.2017.09.013
+
MODEL
2 closed and the hitch stitch is released to confirm appropriate orientation of the ureter. If a stent cannot be placed cystoscopically due to either a stenotic ureterovesical junction or severe proximal tortuosity, an alternate method of excisional tapering and stent placement is effective. Once the distal ureter is mobilized, a hitch stitch is passed percutaneously through the ureter, which is anchored towards the abdominal wall. The ureter is then transected distal to the hitch stitch. With the transected ureter exposed, the ureteral stent is inserted percutaneously in a retrograde fashion. Excisional tapering is then performed and the ureter is reconstructed. The narrowed ureteral segment is excised at the bladder mucosa and the dismembered reimplantation proceeds.
Refluxing megaureter Excisional tapering of the ureter takes place as described above, however since dismembering is not required it is immediately followed by reimplantation.
Results Fourteen patients underwent RALMT with ureteral reimplantation between August 2012 and November 2015. The mean operative time was 276 min, including a bilateral case. Certain components of the procedure may be facilitated by variations in surgical technique, among which we have highlighted ureteral stent insertion, method of excisional tapering, and method of reimplantation. All (10/10) patients who completed postoperative ultrasounds after ureteral stent removal demonstrated radiographic improvement at a mean follow-up of 9 months and none of the patients had postoperative febrile urinary tract infections.
B. Li et al.
Conclusions RALMT with ureteral reimplantation is safe and feasible for treating pediatric obstructive and refluxing megaureters. Technical variations may assist with facilitating optimal surgical outcomes.
Conflict of interest B.W.L. Intuitive surgical: travel/accommodation for faculty role at Intuitive Master’s Course (instructional course). January 2016.
Funding None.
Ethical approval Institutional Review Board approval was obtained.
References [1] Bowen DK, Faasse MA, Liu DB, Gong EM, Lindgren BW, Johnson EK. Use of pediatric open, laparoscopic and robotassisted laparoscopic ureteral reimplantation in the United States: 2000 to 2012. J Urol 2016;196(1):207e12. [2] Grimsby GM, Dwyer ME, Jacobs MA, Ost MC, Schneck FX, Cannon GM, et al. Multi-institutional review of outcomes of robot-assisted laparoscopic extravesical ureteral reimplantation. J Urol 2015;193(5 Suppl.):1791e5.
Please cite this article in press as: Li B, et al., Robot-assisted laparoscopic megaureter tapering with ureteral reimplantation: Tips and tricks, Journal of Pediatric Urology (2017), https://doi.org/10.1016/j.jpurol.2017.09.013