<title>1. INTRODUCTION</title> <p>Open
extravesical ureteral reimplantation is a successful and well-tolerated
procedure with a proven track record in the surgical management of
vesicoureteric reflux (VUR). Nevertheless, the relentless pursuit of minimally
invasive ideals has led to the development of alternatives. Most recently, the
endoscopic injection techniques have become quite popular, but concerns remain
over the success rate and long-term efficacy. Thus, the laparoscopic approach offers another option which improves on
the open procedure with better cosmesis and convalescence, while providing a
durable and successful procedure compared to injection therapy.</p> <p>Despite
multiple reports in the early 1990s of experimental surgery in animal models [##REF##8326639##1##–##REF##7815633##3##]
and few cases in humans [##REF##8116127##4##, ##UREF##0##5##], it was not until the seminal contributions of
the late Leo Fung in 2000 that the technical aspects and outcomes of the
procedure were documented [##REF##11030542##6##]. Since then, the peer reviewed literature has
been sparse, such that the learning curve of this procedure is not well
established. We review our current experience and lessons learned in the
process.</p>
<title>2. MATERIALS AND METHODS</title> <title>2.1. Patients</title> <p>A total of 20
children aged 4–15 years (mean 7.3 years) have undergone laparoscopic extravesical ureteral reimplantation over
a 5-year period. The subjects were mostly female (15 of 20) with 11 (55%) cases
being bilateral. All cases were diagnosed with VUR after urinary infection and
the indication for surgery included breakthrough infection in 18 of 20 and
persistent high-grade VUR in 2 of 20.</p> <p>The highest grade
of reflux per patient ranged from 2 to 4, with only 1 case of unilateral grade
2, that being a case of failed injection therapy. The distribution of VUR per
patient by highest grade was grade 4 in 7 patients (35%), grade 3 in 10 (50%),
and grade 2 in 3 (15%). Megaureters, duplicated ureters, and neurogenic
bladders were excluded initially. Previous open ureteral surgery remains an
exclusion criterion. Bilateral cases are
selected such that one side is not high-grade VUR, so as to minimize the risk
of urinary retention. This hypothesis is based on the postulates that bladder
dysfunction should not occur with unilateral extravesical dissection, and that
high-grade VUR is a risk factor for postoperative bladder dysfunction [##REF##10458465##7##].</p> <p>The postoperative
follow-up regimen includes a routine abdomino-pelvic ultrasound 1 month after
surgery and a voiding cystourethrogram 3 months after surgery, with maintenance
of antibiotic prophylaxis until the VCUG is done. In the absence of new
findings on the first post-op ultrasound, another routine abdomino-pelvic
ultrasound is planned 1 year after surgery.</p> <title>2.2. Technique</title> <p>We
find it useful for learning purposes to divide the case into four specific
tasks: 1-access, 2-uretero-vesical junction exposure, 3-detrusor tunnel
dissection, and 4-tunnel suturing.</p> <title>2.3. Access</title> <p>A 4-port approach
is utilized with the patient in Trendelenburg position, legs spread apart, and
the arms tucked in at the side. A sterile Foley catheter is placed in the
operative field and controlled with a Toomey syringe. A mechanical bowel
preparation can be helpful in patients with constipation. The first port is
supraumbilical, and the 3 others form an arc along the level of the
anterior-superior iliac spine (##FIG##0##Figure 1##). The level of this arc is adjusted
downwards as the patient age increases and the bladder is further from the
umbilicus. The arc is formed by 1 port on either lateral edge of the rectus and
1 midline port. All ports are 5 mm except for the 3 mm inferior midline port. A
zero degree telescope is placed at the upper edge of the umbilicus with 2 video
monitors at the foot of the bed. The surgeon and assistant are contralateral to
the ureter with the assistant holding the camera while seated caudal to the
surgeon.</p> <title>2.4. Exposure
of the ureter</title> <p>The peritoneal
envelope is opened just adjacent to the bladder, caudal to the Fallopian tube or
vas deferens in the male (##FIG##1##Figure 2##). The round ligament is also divided to
further open the peritoneal window. The ureter is readily identified by <italic>blunt</italic> dissection adjacent to the
bladder, often with the superior vesical artery coursing parallel. The assistant
then controls the ureter with a vessel loop (##FIG##2##Figure 3##) through the inferior
midline port which provides the exposure needed for the surgeon to mobilize the
ureter from the pelvic brim to the uretero-vesical junction.</p> <title>2.5. Detrusor
tunnel dissection</title> <p>The bladder is
partially filled via the Toomey syringe, and the planned detrusor tunnel is
exposed with 2 percutaneously passed suspension sutures of 3–0 silk. A fascial
closure device is utilized to pass the hitch stitch percutaneously after an
appropriate exit site has been chosen. These hitch stitches are placed on
either side of the apex of the planned tunnel and should be angled so as to
provide a distraction force to the edges of the detrusor tunnel. The direction
of the planned tunnel should be oriented vertically and its length can be
measured with a piece of ureteral catheter acting as a ruler 
(##FIG##3##Figure 4##). The direction of the tunnel is crucial in
determining subsequent ergonomics of both tunnel dissection and suturing.</p> <p>The planned tunnel
is scored with cautery and the superficial detrusor then cauterized. The
remaining detrusor fibers are sharply divided with scissors from apex of the
tunnel towards the ureterovesical junction 
(##FIG##4##Figure 5##). Careful hemostasis is
needed to maintain exposure. The dissection on the right side is easier for a
right-handed surgeon. The left side tunnel dissection is done with the scissor
in the left lateral port and controlled with the left hand. The right angle
forcep and right angle electrocautery can also be very helpful during the
dissection around the ureterovesical junction. The amount of mucosal bulging
can be adjusted by the volume of bladder filling or via the intraperitoneal
insufflation pressure. Any holes in the mucosa can be closed with a figure of eight
stitch of 5–0 plain. The
mucosal edges of the detrusor tunnel are not undermined.</p> <title>2.6. Tunnel
suturing</title> <p>The ureter is then
advanced into the detrusor trough, and the first stitch defines the
neohiatus. That stitch is then held by
the assistant, while the remainder of the detrusor tunnel is closed. The
bladder is emptied, and the detrusor tunnel closed with interrupted 5–0 PDS suture on a
RB1 needle. The suture is controlled with a 3 mm angled forcep and 3 mm needle
driver. All suturing is back-hand with the instruments medial to the ureter
(##FIG##5##Figure 6##). Interrupted stitches alternate from each end of the tunnel with the
last stitch placed in the mid-tunnel so as to avoid inadvertent suture of the
underlying ureter. Having completed the reimplantation, the bladder traction
sutures are released, and the bladder is cycled to confirm the absence of a
urine leak or kinking of the ureter at the neohiatus. A closed suction drain is
left in cases, where the mucosa was opened. The bladder catheter is removed the
following morning.</p>
<title>3. RESULTS</title> <p>All patients who
have been studied postoperatively with a voiding cystourethrogram (VCUG) have
had resolution of reflux, with 2 cases refusing the post-op VCUG and 1 being
lost to follow-up. One case developed de
novo contralateral grade 2 VUR. Three cases were converted to open
surgery, the first 2 cases, both bilateral, because surgical time had surpassed
4 hours. Case 7 had a nonneurogenic neurogenic bladder with a severely
hypertrophied detrusor which made tunnel dissection difficult.</p> <p>The first 5 cases,
4 of which were bilateral, can be considered the learning curve with operative
times falling consistently below 3 hours for a unilateral case, and 5 hours for
a bilateral case thereafter. Mucosal perforation remains the main determinant
of operative time, in its absence the operative time averages 2 hours per
ureter. Mucosal perforation also remains the main determinant of hospital stay.
The usual case is discharged the following day after having voided, whereas
those with suction drains remain for an extra day of observation. Three cases
have had a mucosal perforation including cases 4, 6, and 20, none of which
leaked postoperatively. There has been 1 complication, that of a distal
ureteral necrosis in case 5 which necessitated open revision with a Boari flap.
In this case, the ureter was held on prolonged traction with a Babcock clamp,
which is no longer used. None of the
cases have experienced postoperative voiding dysfunction.</p>
<title>4. DISCUSSION</title> <p>A
few technical aspects merit greater commentary, especially where there may be
differences with other authors. To begin, though exposure of the ureter is
fastest from the bladder up to the pelvic brim, it may be helpful for the first
few cases to mobilize the ureter from the pelvic brim caudally until one is
familiar with the anatomical orientation of the juxtavesical ureter.
Cystoscopically placed ureteral catheters are not necessary though they were
used in the first few cases to document that the ureter was not obstructed by
an errant detrusor suture. The direction of the detrusorotomy should be
straight up; a medial orientation will lead to kinking of the ureter whereas a
lateral orientation makes for tedious dissection of the submucosal tunnel. The
inverted Y-type detrusorotomy is used sparingly so as to limit the chances of
mucosal injury. Instead, the detrusor tunnel edges are reapproximated with
sutures further away from the ureterovesical junction, so as to limit ureteral
obstruction by compression. If there is tension with the closure, a limited inverted
Y-type dissection is performed.</p> <p>Though all other
authors describe the use of a single traction suture, this author believes that
the use of 2 suspension stitches provides superior exposure of the mucosa as
dissection progresses. In addition, the method of traction suture placement
deserves greater attention. Most authors describe percutaneous passage of a
Keith needle into the abdomen, whereas this author passes an intracorporeal
suture extracorporeally with the use of a fascial closure device. This approach
permits one to better judge the exit site of the stitch based on optimal
exposure and orientation. The opposite and more commonly described approach
commits the surgeon to an exit site before one has a chance to test the effect
on bladder exposure. The direction of tunnel dissection is ergonomically best
from the neohiatus downwards towards the ureterovesical junction.
Unfortunately, this can lead to nuisance bleeding obscuring the exposure of the
remaining mucosa. Ideally, one would want to dissect from the ureterovesical
junction upwards towards the neohiatus that way the bleeding does not obscure
vision, which is impossible with rigid instruments. Perhaps this is an area where the superior
dexterity of the robot may be of benefit.</p> <p>Considering
the multiple options for the
surgical management of VUR currently available, the indications for a
laparoscopic extravesical approach are debated. The families electing to choose
this option are concerned with the success rate of injectables and the mounting
evidence that the product is not durable over the long term. These families
want a successful procedure so as to avoid multiple postoperative VCUG’s or to
minimize the risk of another pyelonephritis in those who have experienced
recurrent pyelonephritis. The advantages of reduced pain and convalescence are
less in the infant population such that the procedure is offered mainly to
school age children. Cosmetic considerations become more important in the
postpubertal population. As a result of this selection process, the case load
is smaller relative to the overall cohort of surgically managed VUR, which does
impact on operative time.</p> <p>Having
chosen a laparoscopic approach, other considerations include whether to use a
transvesical approach or an extraperitoneal approach. Though the extravesical
approach is ideally suited to an extraperitoneal exposure, this author feels
that the extra surgical time involved in creating the space is not warranted.
When one considers that the bowel is not mobilized and that the peritoneal
window used for transperitoneal exposure is so small, it is difficult to
imagine significant adhesions occurring in such a context. I have been impressed in the
cases converted open at how small the peritoneal window was; in fact the bowel
did not enter the wound. Likely for
these reasons, there are no published reports on extraperitoneal ureteral
reimplantation, though extraperitoneal pelvic laparoscopy has been reported for
various procedures [##REF##10556465##8##].</p> <p>The
transvesical approach with pneumobladder was first described by Okamura et al.
with the technique of endoscopic trigonoplasty [##REF##7735807##9##]. This procedure has been
abandoned both by the original authors and others [##REF##8683754##10##–##REF##12576836##13##]. The idea of a pneumobladder was advanced with
the initial attempts at endoscopic Cohen procedure [##REF##10597129##12##, ##REF##11586229##14##]. This approach has
gained popularity [##REF##16053348##15##–##REF##17070297##17##], likely due to concerns over voiding dysfunction with
bilateral extravesical surgery. The largest series to date was recently
reported by Canon et al. [##REF##17499791##18##] with acceptable outcomes, though the success rate
was less than open surgery. It remains to be seen if the morbidity of
laparoscopic unilateral transvesical surgery is greater than the laparoscopic
extravesical approach, similar to the open experience. Despite a large case
load and experience, Canon et al. still needed a bladder catheter for at least
36 hours, likely due to the multiple bladder perforations. In addition, with
proper patient selection, the extravesical approach can be used bilaterally
without voiding dysfunction. Our favorable experience with laparoscopic bilateral extravesical ureteral reimplantation is corroborated by that of Lakshmanan and Fung [##REF##11030542##6##] 
and that of McAchran and Palmer [##REF##16217375##19##] with the open extravesical approach.</p> <p>Laparoscopic
extravesical ureteral reimplantation was popularized by Lakshmanan and Fung 
[##REF##11030542##6##]
with excellent outcomes in their series of 47 patients and 71 ureters. They reported a 100% resolution rate of VUR,
though operative times were not documented. Unfortunately, they also
experienced 3 cases of distal ureteral necrosis and emphasized that the Babcock
clamp should not be used for control of the ureter. Based on this author’s
personal experience as well, I would strongly concur. Since then, Shu et al. [##REF##15253814##20##]
have published excellent outcomes in a postpubertal cohort of 6 female
patients. They comment on how the laparoscopic approach to the pelvis is
relatively easier than open pelvic surgery in adolescents, an opinion shared by
this author. The excellent outcomes with extravesical reimplantation have been
further corroborated in a more challenging set of patients including duplicated
ureters [##REF##16796449##21##], dismembered ureteral tailoring [##REF##17085181##22##], 
and psoas hitch as an adjunct
[##REF##16825070##23##].</p> <p>Nevertheless, in
most series, the occasional problem of mucosal perforation and its attendant
prolonged catheter drainage persists in comparison to open extravesical
surgery. It remains to be seen if the ergonomic advantage of robotic assistance
will be helpful in this regard. Improvements in instrumentation such as a hook
electrocautery which is shielded posteriorly and thus does not cause mucosal
perforation by thermal injury would be of tremendous benefit. Furthermore,
prospective experimental study of the facility of mucosal exposure at different
insufflation pressures and different bladder filling volumes deserves greater
attention.</p>
<title>5. CONCLUSIONS</title> <p>Laparoscopic
extravesical ureteral reimplantation is another option in the surgical
management of vesicoureteric reflux. It offers a greater success rate and
durability compared to injection therapy, while offering cosmetic and
convalescence advantages over open surgery in the older child. The learning
curve of the procedure is reasonable and facilitated by an analysis based on 4
components, namely, access, ureter exposure, tunnel dissection, and tunnel
closure. The component of tunnel dissection is the only one which could benefit
from further improvement, likely accomplished with refinements in instruments
or greater study of the variables which contribute to mucosal perforation. 
</p>
<p>Recommended by Hiep Nguyen</p> <p>Laparoscopic extravesical ureteral reimplantation in children is currently a technically demanding procedure with sparse literature to aid in mastering the learning curve. We present our most recent technique and lessons learned after 20 cases in children 4–15 years of age. The literature is also reviewed to encapsulate the current state-of-the-art.</p>
<fig id="fig1" position="float"><label>Figure 1</label><caption><p>Port placement.</p></caption></fig> <fig id="fig2" position="float"><label>Figure 2</label><caption><p>The peritoneal envelope is opened just
adjacent to the bladder.</p></caption></fig> <fig id="fig3" position="float"><label>Figure 3</label><caption><p>The ureter is mobilized while the assistant
maintains traction with a vessel loop.</p></caption></fig> <fig id="fig4" position="float"><label>Figure 4</label><caption><p>The tunnel should be oriented vertically and
its length can be measured with a piece of ureteral catheter acting as a ruler.</p></caption></fig> <fig id="fig5" position="float"><label>Figure 5</label><caption><p>Dissection of the submucosal tunnel.</p></caption></fig> <fig id="fig6" position="float"><label>Figure 6</label><caption><p>Suturing is back-hand with the instruments
medial to the ureter.</p></caption></fig>
<graphic xlink:href="AU2008-567980.001"/> <graphic xlink:href="AU2008-567980.002"/> <graphic xlink:href="AU2008-567980.003"/> <graphic xlink:href="AU2008-567980.004"/> <graphic xlink:href="AU2008-567980.005"/> <graphic xlink:href="AU2008-567980.006"/>
[{"label": ["5"], "surname": ["Janetschek", "Radmayr", "Bartsch"], "given-names": ["G", "C", "G"], "article-title": ["Laparoscopic ureteral anti-reflux plasty reimplantation. First clinical experience"], "italic": ["Annales d'Urologie"], "year": ["1995"], "volume": ["29"], "issue": ["2"], "fpage": ["101"], "lpage": ["105"]}]
Adv Urol. 2008 Aug 18; 2008:567980