Robot-assisted Laparoscopic Extravesical Ureteral Reimplantation: Technique Modifications Contribute to Optimized
Mohan S Gundeti1, William R Boysen1, Anup Shah1
1Section of Urology, University of Chicago Medicine Comer Children's Hospital, Chicago, IL, USA.
Background:
Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is being adopted at large pediatric urology centers in the United States, but currently there is not consensus on surgical technique to facilitate the best possible outcomes.
Objective:
To describe technique modifications that may lead to improved radiographic vesicoureteral reflux (VUR) resolution.
Design, Setting, And Participants:
Between December 2008 and February 2015, a single surgeon performed RALUR-EV at an academic medical center. Only children with persistent grade 3-5 VUR at age 5 yr on voiding cystourethrogram (VCUG), those who had breakthrough urinary tract infections, or those with renal scarring were selected to undergo surgical correction of VUR with RALUR-EV. Children undergoing RALUR-EV for obstructive megaureter or ureterovesical junction obstruction were excluded. Fifty-eight patients (83 ureters) fit the inclusion criteria.
Surgical Procedure:
We highlighted adjustments to our technique, called LUAA to represent length of detrusor tunnel (L), use of a U stitch (U), placement of permanent ureteral alignment suture (A), and inclusion of ureteral adventitia (A) in detrusorraphy.
Outcome Measurements And Statistical Analysis:
The primary end point was resolution of VUR on postoperative VCUG.
Results And Limitations:
Because technique modifications were made at two distinct time points, we generated three patient groups for comparison. We observed complete resolution of VUR in 82% of ureters, including 8 of 12 ureters (67%), 8 of 11 ureters (73%), and 52 of 60 ureters (87%) for technique modification cohorts 1, 2, and 3, respectively. There were no ureteral complications at median follow-up of 30 mo. Retrospective design and possible confounding from the learning curve limit this study.
Conclusions:
Using the standardized LUAA technique, we demonstrated an improvement in outcomes. Given the wide range of published resolution rates following RALUR-EV, there is a need for standardization of technique to facilitate best possible outcomes. We propose the LUAA technique as a new standard for RALUR-EV to achieve this goal.
Patient Summary:
We examined the safety and efficacy of a minimally invasive surgery in children. We identified several critical adjustments to surgical technique that improve rates of successful outcome.
