Key points

A video of vesicoscopic ureteral reimpantation accompanies this article at http://www.urologic.theclinics.com/

Introduction

Vesicoscopic ureteral reimplantation (VUR) is a relatively common clinical problem in children that is characterized by the retrograde flow of urine from the bladder to the upper urinary tracts. The true prevalence of reflux is difficult to accurately assess because it can be completely asymptomatic. In children with prenatal hydronephrosis, the presence of VUR ranges from 15% in children with little or no residual postnatal hydronephrosis to 38% in children who are found to have significant hydronephrosis or other upper tract anomalies. Multiple studies have shown that between 68% and 85% of grade I to II VUR will spontaneously resolve and grade III VUR will resolve in about 50% of patients.

Approaches to intervention are varied and range from endoscopic injection at the ureterovesical junction to open surgical correction. Dextranomer/hyaluronic acid is a common endoscopic treatment of VUR in the United States. Published success rates of this method range from 68% (duplex ureters) to 89% depending on grade of reflux. Historically, open ureteral reimplant has been the gold standard in treatment of VUR with a success rate approaching 100%. There are multiple minimally invasive surgical options for correction of reflux including purely laparoscopic, robotic-assisted, or endoscopic approaches.

Pure laparoscopic ureteral reimplant using the extravesical approach (LEVUR) has been performed with good results. LEVUR was first performed in a porcine model in 1993, and shortly thereafter, Ehrlich and colleagues performed this surgery in children. In a series of 81 patients in a multi-institutional study, Riquelme and colleagues demonstrated a 95.8% rate of VUR resolution on follow-up imaging after LEVUR. Robotic-assisted extravesical ureteral reimplant (RALUR) has been steadily gaining popularity in pediatric urology. Multiple series have been published demonstrating outcomes of RALUR similar to those of open surgery. However, these studies have also shown a significant disparity in the cost and operative times between robotic and open ureteral reimplantation. One series also demonstrated that the rate of complications was similar between robotic and open reimplant, but the Clavien grade of complication was higher in the robotic group and included ureteral stenosis and urine leak.

Intravesical RALUR is not routinely performed at this time. The working space within the bladder is quite small, making robotic assistance more challenging in this scenario. Published series of intravesical RALUR are few, and patient follow-up is short. As robotic systems currently available continue to evolve, intravesical RALUR may gain popularity in the future. A traditional advantage to intravesical versus extravesical approaches to ureteral reimplant is the decreased risk of postoperative bladder dysfunction, in particular, urinary retention. Nerve-sparing modifications to extravesical ureteral reimplant have been described in both the open and the robotic surgical literature. These modifications to surgical technique and dissection decrease the incidence of postoperative urinary retention.

The idea of minimally invasive intravesical surgery to treat VUR is not new. In 1995, Okamura and colleagues described a technique that used both cystoscopic and laparoscopic instrumentation to perform a trigonoplasty. In this procedure, the trigone is resected in a “fanwise” fashion and the ureteral orifices were brought medially by reapproximating the lateral aspects of the trigone with extracorporeal suturing. Follow-up studies of this procedure, however, demonstrated poor rates of reflux resolution in children when compared with adults undergoing the same procedure. Postoperatively, the pediatric patients in these series tended to have trigonal splitting resulting in the return of reflux in 41% of patients. Other drawbacks to this technique included long operative times, including a case that took 6 hours secondary to continued loss of insufflation and difficult visualization.

In 2001, Gill and colleagues described a minimally invasive intravesical technique for VUR correction. The technique was first detailed in a published series of 3 patients. The procedure used glycine irrigation within the bladder and an electrosurgical Collins knife to perform a transurethral detrusor incision. After the detrusor incision is made, a submucosal cross-trigonal trough is made with laparoscopic instruments. The ureters are mobilized intravesically and brought across the trigone and secured in the submucosal tunnels by closing the bladder mucosal flaps over the ureters. Continuous bladder irrigation was used to provide bladder distention and visualization during the surgery. This method introduced intracorporeal suturing to intravesical ureteral reimplantation as well as ureteral dissection.

Yeung and colleagues modified the procedure in 2005 and, instead of glycine irrigation, the bladder was insufflated with carbon dioxide mimicking traditional laparoscopy. The initial published report of this technique included 16 patients with a 96% rate of reflux resolution. Multiple groups have demonstrated good results with this technique. In 2006, a series of 32 patients undergoing vesicoscopic reimplantation (VR) was reported by Kutikov and colleagues. In this series, 92.6% of patients had resolution of VUR; however, there was a relatively high complication rate with postoperative urine leak in 12.5% and ureteral stricture in 6.3% of patients. Importantly, this study showed that most of complications were encountered in patients less than 2 years of age or with a bladder capacity less than 130 mL. This study established the importance of patient selection with the VR technique. In 2007, the authors published a series of 52 children who underwent VR. In their initial series, reflux resolution was 91% in the VR patients compared with 97% in patients who underwent open ureteral reimplantation. The analgesic requirements were less in the VR group, and patients also subjectively described less discomfort. In the authors’ updated 2008 series of 100 patients, 94% of patients who underwent postoperative imaging had complete resolution of reflux. Improvement in the success rate of the surgery is attributed to increased surgeon experience with VR as well as technical adjustments to the procedure over time. Valla and colleagues also published encouraging results with the VR technique in 2009, demonstrating a success rate of 92% in 72 patients with primary VUR. VR has been established as a good option for surgical repair of VUR requiring correction. The authors’ extended experience of 167 patients who have undergone VR is presented here.

Introduction

Vesicoscopic ureteral reimplantation (VUR) is a relatively common clinical problem in children that is characterized by the retrograde flow of urine from the bladder to the upper urinary tracts. The true prevalence of reflux is difficult to accurately assess because it can be completely asymptomatic. In children with prenatal hydronephrosis, the presence of VUR ranges from 15% in children with little or no residual postnatal hydronephrosis to 38% in children who are found to have significant hydronephrosis or other upper tract anomalies. Multiple studies have shown that between 68% and 85% of grade I to II VUR will spontaneously resolve and grade III VUR will resolve in about 50% of patients.

Approaches to intervention are varied and range from endoscopic injection at the ureterovesical junction to open surgical correction. Dextranomer/hyaluronic acid is a common endoscopic treatment of VUR in the United States. Published success rates of this method range from 68% (duplex ureters) to 89% depending on grade of reflux. Historically, open ureteral reimplant has been the gold standard in treatment of VUR with a success rate approaching 100%. There are multiple minimally invasive surgical options for correction of reflux including purely laparoscopic, robotic-assisted, or endoscopic approaches.

Pure laparoscopic ureteral reimplant using the extravesical approach (LEVUR) has been performed with good results. LEVUR was first performed in a porcine model in 1993, and shortly thereafter, Ehrlich and colleagues performed this surgery in children. In a series of 81 patients in a multi-institutional study, Riquelme and colleagues demonstrated a 95.8% rate of VUR resolution on follow-up imaging after LEVUR. Robotic-assisted extravesical ureteral reimplant (RALUR) has been steadily gaining popularity in pediatric urology. Multiple series have been published demonstrating outcomes of RALUR similar to those of open surgery. However, these studies have also shown a significant disparity in the cost and operative times between robotic and open ureteral reimplantation. One series also demonstrated that the rate of complications was similar between robotic and open reimplant, but the Clavien grade of complication was higher in the robotic group and included ureteral stenosis and urine leak.

Intravesical RALUR is not routinely performed at this time. The working space within the bladder is quite small, making robotic assistance more challenging in this scenario. Published series of intravesical RALUR are few, and patient follow-up is short. As robotic systems currently available continue to evolve, intravesical RALUR may gain popularity in the future. A traditional advantage to intravesical versus extravesical approaches to ureteral reimplant is the decreased risk of postoperative bladder dysfunction, in particular, urinary retention. Nerve-sparing modifications to extravesical ureteral reimplant have been described in both the open and the robotic surgical literature. These modifications to surgical technique and dissection decrease the incidence of postoperative urinary retention.

The idea of minimally invasive intravesical surgery to treat VUR is not new. In 1995, Okamura and colleagues described a technique that used both cystoscopic and laparoscopic instrumentation to perform a trigonoplasty. In this procedure, the trigone is resected in a “fanwise” fashion and the ureteral orifices were brought medially by reapproximating the lateral aspects of the trigone with extracorporeal suturing. Follow-up studies of this procedure, however, demonstrated poor rates of reflux resolution in children when compared with adults undergoing the same procedure. Postoperatively, the pediatric patients in these series tended to have trigonal splitting resulting in the return of reflux in 41% of patients. Other drawbacks to this technique included long operative times, including a case that took 6 hours secondary to continued loss of insufflation and difficult visualization.

In 2001, Gill and colleagues described a minimally invasive intravesical technique for VUR correction. The technique was first detailed in a published series of 3 patients. The procedure used glycine irrigation within the bladder and an electrosurgical Collins knife to perform a transurethral detrusor incision. After the detrusor incision is made, a submucosal cross-trigonal trough is made with laparoscopic instruments. The ureters are mobilized intravesically and brought across the trigone and secured in the submucosal tunnels by closing the bladder mucosal flaps over the ureters. Continuous bladder irrigation was used to provide bladder distention and visualization during the surgery. This method introduced intracorporeal suturing to intravesical ureteral reimplantation as well as ureteral dissection.

Yeung and colleagues modified the procedure in 2005 and, instead of glycine irrigation, the bladder was insufflated with carbon dioxide mimicking traditional laparoscopy. The initial published report of this technique included 16 patients with a 96% rate of reflux resolution. Multiple groups have demonstrated good results with this technique. In 2006, a series of 32 patients undergoing vesicoscopic reimplantation (VR) was reported by Kutikov and colleagues. In this series, 92.6% of patients had resolution of VUR; however, there was a relatively high complication rate with postoperative urine leak in 12.5% and ureteral stricture in 6.3% of patients. Importantly, this study showed that most of complications were encountered in patients less than 2 years of age or with a bladder capacity less than 130 mL. This study established the importance of patient selection with the VR technique. In 2007, the authors published a series of 52 children who underwent VR. In their initial series, reflux resolution was 91% in the VR patients compared with 97% in patients who underwent open ureteral reimplantation. The analgesic requirements were less in the VR group, and patients also subjectively described less discomfort. In the authors’ updated 2008 series of 100 patients, 94% of patients who underwent postoperative imaging had complete resolution of reflux. Improvement in the success rate of the surgery is attributed to increased surgeon experience with VR as well as technical adjustments to the procedure over time. Valla and colleagues also published encouraging results with the VR technique in 2009, demonstrating a success rate of 92% in 72 patients with primary VUR. VR has been established as a good option for surgical repair of VUR requiring correction. The authors’ extended experience of 167 patients who have undergone VR is presented here.

Indications/contraindications

VR at the authors’ institution is performed on children older than 4 years. The authors have found that older children benefit the most from this procedure and the intravesical space is typically sufficient in this age group. Because VR is technically demanding and involves complex reconstruction in a limited space, the authors continue to be selective in offering VR to patients in whom no ureteral tapering is anticipated. Most children who underwent the procedure were between 5 and 6 years of age with persistent VUR or symptomatic urinary tract infection. In children with grade IV VUR, VR was offered only if ureteral tapering was thought to be unlikely. Ureteral duplication is not considered a contraindication to VR. Patients with duplex ureters underwent common sheath VR.