# Technique of Intravesical Laparoscopy for  Ureteric Reimplantation to Treat VUR

Authors: Atul A. Thakre; C. K. Yeung
Journal: Advances in Urology
 (2008)

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## Abstract

The prevalence of vesicoureteral reflux (VUR) has been estimated as 0.4 to 1.8% among the pediatric population. In children with urinary tract infection, the prevalence is typically from 30–50% with higher incidence occurring in infancy. When correction of VUR is determined to be necessary, traditionally open ureteral reimplantation by a variety of techniques has been the mainstay of treatment. This approach is justified because surgical correction affords a very high success rate of 99% in experienced hands and a low complication rate. In that context the purpose of presenting oursurgical technique: laparoscopic intravesical ureteric reimplantation is to highlight the use of laparoscopy to perform ureteric reimplantation for the management of pediatric VUR.


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## Body

## 1. Surgical Technique: Laparoscopic Intravesical Ureteric Reimplantation

The  patient is  positioned  supine with the legs separated apart for cystoscopy and
bladder catheterization intraoperatively. For small infants, the surgeon can
stand and operate over the patient’s head whereas for older children, the
surgeon usually stands on the patient’s left side. The video column is placed
between the patient’s legs at the end of the table. The port placement is
preceded by transurethral cystoscopy to allow placement of the first camera
port under cystoscopic guidance. The bladder is first distended with saline and
a 2-0 monofilament traction suture is passed percutaneously at the bladder dome under
cystoscopic vision, through both the abdominal and bladder walls. This helps to
keep the bladder wall from falling away when the first camera port site
incision is made and during  insertion of the cannula. A 5-mm Step port (Tyco Healthcare Group LP, Conn, USA) is then inserted under
cystoscopic vision. A urethral catheter is then inserted to drain the bladder
and start carbon dioxide insufflation to 10–12 mm Hg
pressure. The urethral catheter is used to occlude the internal urethral meatus
to secure CO2 pneumovesicum, and it could also serve as an additional suction irrigation
device during subsequent dissection and ureteric reimplantation. A 5-mm
30-degree scope is used to provide intravesical vision. Two more 3–5 mm working
ports are then inserted along the interspinous skin crease on either side of
the lower lateral wall of the distended bladder under vesicoscopic guidance (see
Figure 1). A 3-4 cm long segment
of an Fr 4 or 6 catheter is then inserted into the respective ureter as a stent
to facilitate subsequent ureteral mobilization and dissection, and secured with
a 4-zero monofilament suture (see Figure 2). Intravesical mobilization of the
ureter, dissection of submucosal tunnel, and a Cohen’s type of ureteral
reimplantation is then performed under endoscopic guidance, in a similar manner
to the open procedure.Figure 1
5-mm working ports inserted along the interspinous skin crease on either
side of the lower lateral wall of the distended bladder under vesicoscopic
guidance.Figure 2
A 3-4 cm long segment
of an Fr 4 or 5 catheter is inserted into the ureter as a stent to facilitate
subsequent ureteral mobilization and dissection, and secured with a 4-zero
monofilament suture.The
ureter is mobilized by first circumscribing it around the ureteral orifice
using hook electrocautery (see Figure3). With traction on the ureteric stent
using a blunt grasper, the fibrovascular tissue surrounding the lower ureter
can be seen and divided using fine 3-mm endoscopic scissors and diathermy hook,
while preserving the main ureteric blood supply (see
Figure 4). Mobilization of the ureter is continued for 2.5 to 3 cm to the
extravesical space. Once adequate ureteral length is obtained, the muscular
defect in the ureteral hiatus is repaired using 5-zero absorbable sutures,
usually with an  extracorporeal knot-tying technique  (see Figure 5). A
submucosal tunnel is then created as in an open Cohen’s procedure. Using a
diathermy hook, a small incision is made over the future site of the new
ureteral orifice, usually chosen to be just above the contralateral ureteral
orifice. Dissection of the submucosal tunnel is then started from the medial
aspect of the ipsilateral ureteral hiatus towards the new ureteral orifice,
using a combination of endoscopic scissor dissection and diathermy hook for
haemostasis. Once the submucosal tunnel dissection is completed, a fine grasper
is passed and the mobilized ureter is gently drawn through the tunnel.
Ureteroneocystostomy is performed under endoscopic guidance with intracorporeal
suturing using interrupted 5-0 or 6-0 poliglecaprone or polydioxanone sutures (see Figures 6, 7). A ureteral stent is not routinely used except for selected
patients undergoing bilateral ureteral reimplantation or those with megaureters
requiring tapering ureteroplasty. The working ports are removed under
endoscopic vision with evacuation of the pneumovesicum. The bladder-holding
stitches are then tied. Each port site entry wound is then closed with a subcuticular
monocryl suture.Figure 3
The ureter is mobilized by first circumscribing it around the ureteral
orifice using hook electrocautery.Figure 4
With traction on the ureteric stent using a blunt grasper, the fibrovascular
tissue surrounding the lower ureter can be seen and divided using fine 3-mm
endoscopic scissors and diathermy hook, while preserving the main ureteric
blood supply.Figure 5
Once adequate ureteral length is obtained, the muscular defect in the
ureteral hiatus is repaired using 5-zero absorbable sutures, usually with an
extracorporeal knot-tying technique.Figure 6
Ureteroneocystostomy is performed under endoscopic guidance with
intracorporeal suturing using interrupted 5-0 or 6-0 poliglecaprone or
polydioxanone sutures.Figure 7
Completed ureteroneoctostomy.


## 2. Results

The operative success for laparoscopic  Cohen’s is encouraging [1–3]  and endoscopic intravesical ureteric mobilization and cross-trigonal
ureteral reimplantation can be safely performed with routine pediatric
laparoscopic surgical techniques and instruments under carbon dioxide
insufflation of the bladder [1].We have not faced any major complications with this
technique. In the early part of the series when the cannulas were not secured
to the bladder wall, displacement of the port outside the bladder wall
occurred. This resulted in gas leakage into the extravesical space, with
compromise of the intravesical space and endoscopic vision. It is usually
possible to reintroduce the ports but securing the ports perfectly is the key
to the success of this technique [1]. We have experienced mild to moderate scrotal and suprapubic
emphysema immediately postoperatively, which subsided spontaneously within 24 hours. Persistent mild haematuria up to 72 hours has also been observed, which
too settles spontaneously. A recent series has reported complications of postoperative urinary leak in (12.5%) and ureteral stricture at the
neoureterovesical anastomosis in (6.3%). This series also reported higher
complications in patients 2 years or younger with bladder capacity less than
130 cc. [2].


## 3. Discussion

Laparoscopic surgery has gradually made its place in
surgically dealing vesicoureteral reflux. Laparoscopic extravesical and
intravesical surgeries have shown good early results [1–3]. It also showed that children benefit from the improved cosmesis,
more rapid recovery, and decreased postoperative analgesia requirements with the laparoscopic
technique. Initial experience reported
increased operative time and  a
steep learning curve [2], but
these issues have been overcome with
greater experience [1]. Greatest technical merit with high
level of surgical precision is required to do this surgery. The operation
desires extreme care, gentleness, and tissue respect while dissecting out the ureters. Great care needs to be taken to prevent damage to
the ureteric vascularity which is an important cause which leads to developing
ureteric necrosis and strictures. Laparoscopy aids fine dissection of the
ureter and the submucosal tunnel with minimal trauma to the bladder wall and
mucosa. The bladder can be quickly rehabilitated after surgery and normal
voiding is ensured in the long term. To obtain the highest possible success
with this operation, the decisive technical details described should be
meticulously observed [1] supported by very good laparoscopic reconstruction skills to
achieve these results.



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