Journal of Pediatric Urology (2012) 8, 83e86
Transvesicoscopic cross-trigonal ureteroneocystostomy in children: A single-center experience Haluk Emir*, Emil Mammadov, Mehmet Elicevik, Cenk Buyukunal, Yunus Soylet Division of Pediatric Urology, Department of Pediatric Surgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey Received 15 July 2010; accepted 11 October 2010 Available online 16 November 2010
KEYWORDS Vesicoureteral reflux; Ureteric reimplantation; Ureteroneocystostomy; Laparoscopic; Minimally invasive
Abstract Purpose: To evaluate the safety and efficacy of transvesicoscopic ureteric reimplantation in children. Patients and methods: Seventeen ureteric units in 11 patients underwent a transvesicoscopic ‘Cohen’ ureteroneocystostomy in 2003e2007 and the results were retrospectively analyzed. There were four boys and seven girls. All patients had vesicoureteric reflux (VUR), except for one with paraostial diverticula. Six patients underwent bilateral and five unilateral transvesicoscopic reimplantation (a total of 17 units). Results: The procedure was successfully completed in all patients. Mean operation time was 217 min in unilateral cases and 306 min in bilateral cases without perioperative complications, except for pneumoperitoneum development in two cases. In the early postoperative period, two patients developed macroscopic hematuria. Mean hospital stay was 3.8 days (3e5 days), except for one patient who suffered from urinary tract infection and needed longer hospitalization. Mean follow-up period was 4.5 years (3e7 years). One patient with bilateral VUR had passive unilateral grade I VUR on postoperative cystogram, giving a success rate of 91% (94% of ureters). This patient was followed conservatively. One patient had recurrent urinary tract infections without reflux. Conclusion: Transvesicoscopic cross-trigonal ureteroneocystostomy can be safely performed with a high success rate in children. ª 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ90 532 232 33 85; fax: þ90 212 414 33 14. E-mail address:
[email protected] (H. Emir). 1477-5131/$36 ª 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2010.10.005
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Introduction Surgical treatment of vesicoureteral reflux (VUR) started with open-approach ureteral reimplantation in the late 1950s and was popularized by several extra and intravesical reimplantation techniques developed in the 1960s and 70s. In the 1980s, the concept of subureteric injection was popularized, to give minimal interventional discomfort to the patient. In the early 1990s, the term laparoscopic repair first came to attention [1e3]. The laparoscopic approaches proposed up until now take open techniques as their basis. Several authors and institutions have reported series with a relatively high success rate [4e9]. However, the success rates are slightly lower than with traditional open repair, which places these procedures somewhere between endoscopic injection and the classic open reimplantation technique [4e9]. It seems that there is still a necessity for more extensive series and longer follow up to decide on this issue. In this report, we present our preliminary results with the transvesicoscopic cross-trigonal ureteric reimplantation technique in children.
Materials and methods Eleven patients (4 boys and 7 girls) who underwent transvesicoscopic ‘Cohen’ ureteroneocystostomy in our clinic between the years 2003 and 2007 were retrospectively analyzed. Mean age at operation was 6.9 years (2e15 years). Ten of the patients had VUR (4 unilateral, 6 bilateral); one patient was diagnosed with paraostial bladder diverticula without reflux. Nine patients had urinary dilatation on preoperative urinary ultrasonography. The reflux was grade II in one patient, grade III in three patients and grade IV in six patients. Also, nine patients had renal scarring on static scintigraphy. Six patients underwent videourodynamic investigation for suspected bladder dysfunction, and four of them had positive urodynamic findings requiring appropriate medical therapy. One patient had mild renal insufficiency at the time of diagnosis. All patients had recurrent urinary tract infections (UTIs). Surgical indications for VUR were recurrent UTIs and/or new renal scarring. High-grade reflux, which possibly would need ureteric remodeling, and history of previous unsuccessful open surgery were the main exclusion criteria for transvesicoscopic surgery. After obtaining parental permission, six patients underwent bilateral and five patients underwent unilateral reimplantation (total of 17 units). One patient had undergone previous bilateral and another patient unilateral unsuccessful subureteric injection attempts with hyaluronic acid/dextranomer. The principles of operative technique were similar to those described by C.K. Yeung (personal communication) and the methodology of the technique is also described in detail by Thakre and Yeung [10]. The procedure was started by intravesical insertion of a 5-mm port under cystoscopic guidance. Two additional 3.9-mm ports were inserted as working ports. Vision was achieved by a 5-mm zero-degree optic camera. A transurethral catheter was inserted, being used for both suction and irrigation. Following mobilization of the ureter, the
H. Emir et al. hiatal defect was repaired. A submucosal tunnel was created and ureteric reimplantation was performed by separate 5/0 or 6/0 absorbable sutures.
Results The transvesicoscopic procedure was successfully completed in all patients without perioperative complications except for pneumoperitoneum development in two cases. Mean operation time was 217 min in unilateral cases and 306 min in bilateral cases. In the early postoperative period, two patients developed macroscopic hematuria. The urethral catheter was removed on day 3 following surgery, except in two patients who developed hematuria. Mean hospital stay was 3.8 days (3e5 days), except for one patient who suffered from urinary tract infection and needed longer hospitalization. Mean follow-up period was 4.5 years (3e7 years). Only one patient with bilateral VUR had passive unilateral grade I reflux on postoperative cystogram (Fig. 1), giving a success rate of 91% (94% of ureters). This patient did not have clinical complaints and was followed conservatively. Also, one patient has recurrent UTIs without reflux. All of the patients are being followed up in cooperation with the Pediatric Nephrology Department.
Discussion Although under investigation, the presence of high-grade reflux, recurrent UTIs and development of new renal scarring are still accepted as indications for surgical treatment of VUR. Surgery is also considered as an option in patients refusing continuous medical suppression therapy or medication-free observation. After being introduced to medicine in the early 1980s by O’Donnell and Puri, subureteric injection has gained widespread acceptance among pediatric urologists as a minimal invasive alternative to surgical treatment of VUR [11]. However, the success rates of this procedure remain lower compared to ureteric reimplantation [12]. Laparoscopy was proposed as an option in the early 1990s with the endoscopic adaptation of the LicheGregoir technique [8,13e17], followed by the transvesicoscopic approach [5,18]. The first reimplantation series with favorable results came nearly a decade after [4e9]. Endoscopic techniques of reimplantation adhere to the main principles of the open approaches. The procedure may be accomplished either in an extravesical or intravesical manner depending on the capability of the surgeon. The intravesical repair technique evolved from the first experience of performance in a fluid-filled medium, progressing to carbon dioxide insufflations of the bladder [5,6,10] which gave a better quality of view and manipulation. Yeung and colleagues, who had the first experience with ‘pneumovesicum’, reported a 96% success rate in 16 patients in 2005 [6]. Canon and colleagues were the first to compare the transvesicoscopic technique to open, and reported a 91% and 97% success rate, respectively [7]. Valla and colleagues reported a 92% success rate in 72 patients in 2009 [4]. The reflux correction rate in our series was 91% (94% of ureters) with no conversion to open technique. There was
Transvesicoscopic ureteric reimplantation
Figure 1
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Preoperative and postoperative cystogram showing postoperative unilateral grade I reflux (arrow).
no major complication related to the operation. It is obvious that the operative time of transvesicoscopy is longer than for open surgical techniques. Our operative time appears longer than those stated in previous reports [4e7,18]. This is mainly because of the small number of cases, covering the beginning of our experience. Although the operating time of recent cases is acceptably shorter, these were not included so that we could focus on the longer follow-up results of the technique. The main advantages of endoscopic surgery are the reduction of hospital stay, better cosmesis and less postoperative discomfort. But one should remember that in the development timeline, changes in treatment protocols such as better pain management and catheterless reimplantation have left only ‘better cosmesis’ as ammunition in the hands of minimal invasive surgeons. As a center that gained benefit from these revisions of management protocols, we suggest very careful selection of patients for this procedure. However, the present results have encouraged us to proceed, believing that transvesicoscopic ureteric reimplantation will replace the open reimplantation approach in the future.
Conflict of interest/funding None.
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