Single-Port Robotic-Assisted Pneumovesicoscopic Cohen Ureteral Reimplantation for Persistent High-Grade Bilateral...

High-grade vesicoureteral reflux (VUR) may require definitive reconstruction when conservative or endoscopic management fails. Although robot-assisted ureteral reimplantation is increasingly used in children, published experience has predominantly involved an extravesical approach or multiport intravesical surgery. We describe a pure intravesical Cohen reimplantation performed with the da Vinci Single Port (SP) system.

A 7-year-old girl had recurrent febrile urinary tract infections and acute pyelonephritis despite two previous dextranomer/hyaluronic acid copolymer injections. Voiding cystourethrography demonstrated persistent bilateral VUR (right grade V and left grade IV). Technetium-99m dimercaptosuccinic acid renal scintigraphy showed differential renal function of 38.98% on the right and 61.02% on the left, with cortical defects consistent with renal scarring. She underwent single-port robot-assisted pneumovesicoscopic bilateral Cohen ureteral reimplantation. The previous injectable material was removed, bilateral cross-trigonal submucosal tunnels were created, and both ureters were reimplanted with interrupted 5-0 polyglactin sutures. The total anesthesia duration, operative duration and console duration was 375 min, 310 min and 250 min, respectively. There was minimal blood loss and no drainage tubes or Double J stents were placed. No intraoperative complication occurred. A transient episode of emesis with stool impaction on postoperative day 2 resolved after a glycerin enema and brief bowel rest. She tolerated a regular diet by postoperative day 4 and was discharged on postoperative day 5. At early 6-month follow-up, the patient remained symptom free and ultrasonography showed no obstruction.

This case demonstrates the technical feasibility of a pure intravesical da Vinci SP Cohen reimplantation in a child with refractory bilateral high-grade VUR. Comparative effectiveness of different approaches and longer clinical follow-up are required in the future.