# Vesicoscopic Ureteral Reimplantation: A Minimally Invasive Technique for the Definitive Repair of Vesicoureteral Reflux

Authors: Venkata Jayanthi; Ashay Patel
Journal: Advances in Urology
 (2008)

---

## Abstract

The surgical treatment of vesicoureteral relfux can range from injection therapy to open ureteral reimplantation.  Minimally invasive applications for treatment of vesicoureteral relfux include laparoscopic extravesical and intravesical ureteral reimplantation.  We present our extended experience of the technique for intravesical cross-trigonal ureteral reimplantation for vesicoureteral relux.


---

## Body

## 1. Introduction

As in all areas of
surgery, there is an ever increasing interest in minimally invasive techniques. Injection therapy using dextranomer/hyaluronic acid is a simple technique with
low morbidity but most studies would suggest that this approach is not as
successful as standard repair. Laparoscopic reconstructive surgery, for
whatever underlying pathologic condition, has the expectation and advantage
that as one tries to follow the same principles as with open repair, after the
learning curve period, success rates should be identical.Most reports of
laparoscopic repair of reflux have described the use of an extravesical
technique with relatively good success rates. Many urologists however prefer to
correct reflux using an open transvesical approach. The
feasibility to replicate this technique using  a vesicoscopic approach was demonstrated by
Gill et al. [1] Yeung
however was the first to present a large series of patients undergoing
cross-trigonal ureteral reimplantation using CO2 pneumovesicum with success
rates nearly identical to standard open repair [2]. Simiarly, Valla et
al. reported their experience with this technique again demonstrating high
success rates [3]. Kutikov et al. presented their initial experience
with vesicoscopic reimplantation for both primary reflux and megaureter repair [4]. A retrospective review from our center has demonstrated decreased pain in
patients undergoing a vesicoscopic approach compared to standard Cohen repair [5].
In this report, we present our extended experience with vesicoscopic
cross-trigonal ureteral reimplantation.


## 2. Materials and Methods

### 2.1. Patient Selection

Our
preference is to use this technique only in children with primary reflux (less
than grade IV) who have seemingly normal bladder function based on clinical
history or have dysfunctional elimination syndrome responsive to standard
treatments.  Though there are some
published reports of using a vesicoscopic technique for megaureter repair, we
have elected to use this technique only in situations where tapering would not
be needed. We have performed this procedure in children as young as 13 months,
but there realistically may not be much of an advantage in performing
vesicoscopic repair in children less than 2 years of age. The decreased working
space in younger children does make the procedure more technically demanding
and may obviate the advantages of vesicoscopic repair. Preoperative bladder volume was not utilized
to evaluate inclusion criteria for surgical consideration. Failed injection therapy does make dissection
more complicated but should not be considered a contraindication.


### 2.2. Surgical Technique

Positioning
The
procedure is performed with the child in the dorsal lithotomy position with the
abdomen and perineum within the sterile field (Figure1). Urethral access is
needed at various times during the procedure. Due to the extended length of the
procedure, careful positioning and padding of the legs is needed to prevent
nerve palsy.
The
surgeon typically stands on the patient’s left side with the monitor positioned
over the right leg. The assistant, that is, camera holder, stands on the
patient’s right looking at a monitor positioned over the left leg. The scrub
nurse typically stands between the legs.Patient is placed in dorsal lithotomy position
with the surgeon standing to the patient’s left looking at a monitor over the
right leg.
(a)(b)Bladder Wall Fixation and Port Placement
After
positioning the patient, using a pediatric cystocope rigid cystourethroscopy is
performed using a 30-degree lens during the fixation of the bladder wall. Fixation of the bladder to the anterior
abdominal wall is critical for several reasons. Firstly, it can be difficult to
push a port through fascia and bladder wall. Fixation of the bladder will
create enough resistance to allow ports to be more easily introduced. Secondly,
in case of inadvertent removal of the port during the procedure, having the
bladder fixed to the abdominal wall will maintain the relationship between the
skin incision and the entry site within the bladder permitting replacement of
the port. Pneumovesicum is created using CO2 introduced through the irrigation
port of the cystoscope at maximal pressures of 10–15 mm Hg. Once the bladder is maximally
distended, under cystoscopic guidance the dome and lateral walls of the bladder
are fixed to the abdominal wall. The present technique for placement of the
fixation sutures is adapted from a report on percutaneous internal ring
suturing, a method for percutaneously closing the patent processus vaginalis in
children with inguinal hernias or communicating hydroceles [6].
Briefly, a 2-0 PDS suture is placed through an 18 guage spinal needle. Under
cystoscopic guidance, the spinal needle is introduced into the bladder (Figure 2(a)). This will naturally push the suture into the bladder. Upon extraction of
the needle, a loop of suture, called the pulling loop, will be left in the
bladder. Through an adjacent puncture, the spinal needle is inserted into the
bladder and through the pulling loop (Figure 2(b)). One end of the suture that
formed the pulling loop is then inserted through the needle, thus placing it
through the loop (Figure  2(c)). Retracting the pulling loop out of the bladder pulls
the free end of the suture creating a through-and-through suture which can be
tied fixing the bladder to the abdominal wall (Figure 2(d)). Fixation sutures are
placed in the midline as well as the lateral walls of the bladder. A 5 mm port
is placed in the midline for the camera and two 3 mm ports placed laterally for
the working ports. These ports are placed immediately distal to the fixation
sutures in the direction of the bladder neck. It is often helpful to place a
purse string suture around the ports to further immobilize them, minimizing the
chances for inadvertent removal. For
most children, 3 mm laparoscopic instruments that are 20 cm in length are
ideal.(a) Spinal needle has pushed
suture into bladder creating pulling loop. (b) Spinal needle passed
through pulling loop via an adjacent puncture. (c) With needle through
pulling loop, one free end of the suture is passed through spinal needle and
thus the pulling loop. (d) Removal of spinal needle
results in suture being snared by pulling loop. Subsequent retraction of
pulling loop creates through-and-through suture which can then be tied fixing
bladder to abdominal wall.
(a)(b)(c)(d)Ureteral Dissection
Vesicoscopy
is performed using a 5 mm 30-degree lens. The orientation is such that the
bladder neck will be located at the 12:00 position (Figure3). Feeding tubes (3.5 Fr.) are placed per urethra, passed up
each ureter, and fixed with fine suture. Dissection is begun by using a hook electrode
at a power setting of 10 (low power) (Figure 4(a)). Lifting up on the suture holding
the feeding tube in place will create sufficient tension such that incision of
the bladder mucosa with the hook electrode will cause the bladder to fall back.
In a manner analogous to open transvesical surgery, the ureter can be mobilized
from the surrounding detrusor muscle using a combination of sharp and blunt
dissection. Extreme care must be used when transecting investing bands of
detrusor and it may be safer to divide these bands sharply as opposed to using
cautery (Figure 4(b)). This dissection is rather easy and rapid in children with
thin-walled bladders but can be quite difficult if a child has a markedly
thickened bladder wall. Dissection is
continued until enough length is gained to bring the ureter to the
contralateral side (Figure 4(c)). The posterior detrusor opening is then closed with
interrupted 4-0 polydioxanone suture. For bilateral repairs, the contralateral
ureter may then be mobilized (Figure 4(d)).
During the
procedure a suction device is needed to remove not only blood but also urine
that may accumulate at the bladder base. Some authors have left a small
urethral catheter indwelling to assist with suction but our preference is to
simply use a 3 mm suction-irrigation device through one of the working ports as
needed.Figure 3
Initial “vesicoscopic”
view of operative site in a patient that had failed prior injection therapy.(a) Initial dissection with
hook electrode at low-power setting. (b) Investing detrusor bands
divided using sharp dissection. (c) Ureter has been
mobilized such that it can reach the contralateral side with no tension. (d) View after bilateral
mobilization and closure of the posterior detrusor openings. Ureters have been
pushed back out of bladder to permit visualization of the bladder
mucosa-detrusor plane to permit creation of the submucosal tunnels.
(a)(b)(c)(d)Tunnel Creation
Cross-trigonal
tunneling is then performed with a combination of blunt and sharp dissection in
the submucosal plane (Figure5(a)). Maryland
graspers are used to elevate the mucosa and fine scissors are used to initiate
and develop the plane. The positive pressure within the bladder along with the
optics of the 30-degree lens can assist with the visualizing the appropriate
plane. The length of the tunnel created spans from the initial hiatus across to
the contralateral hiatus. After creation of the tunnel(s), the ureters may be
placed in the tunnels and passed to the other side. The ureter(s) is then fixed
in place with 5-0 polydioxanone suture (Figure 5(b)). The remaining mucosal openings
are then closed with absorbable sutures and the feeding tubes removed (Figures 5(c) and 5(d)).(a) Creation of the
submucosal tunnels started by gently lifting up on mucosa and sharp dissection
of the appropriate plane. (b) The right ureter has
been passed through the tunnel and sutured to the original hiatus on the
contralateral side. (c) Both ureters have been
transposed and sutured in place. The left mucosal opening is then closed with absorbable
suture. (d) Completed repair prior
to removing feeding tubes.
(a)(b)(c)(d)Bladder Port Closure
To
maintain the pathway through the incision into the bladder, a feeding tube is
placed through each port prior to its removal. Under cystoscopic guidance, the bladder
ports are closed using sutures placed in a manner analogous to the initial
fixation sutures. After placing the bladder port closure sutures, a foley
catheter is inserted to decompress the bladder and the fixation sutures are
removed. This allows the bladder to fall away from the abdominal wall. The
bladder port sutures are then carefully tied and the skin incisions
subsequently closed.
The
foley catheter is typically removed in 36 hours. Followup imaging included
renal ultrasonography at one month and cystography at 3 months.


## 2.1. Patient Selection

Our
preference is to use this technique only in children with primary reflux (less
than grade IV) who have seemingly normal bladder function based on clinical
history or have dysfunctional elimination syndrome responsive to standard
treatments.  Though there are some
published reports of using a vesicoscopic technique for megaureter repair, we
have elected to use this technique only in situations where tapering would not
be needed. We have performed this procedure in children as young as 13 months,
but there realistically may not be much of an advantage in performing
vesicoscopic repair in children less than 2 years of age. The decreased working
space in younger children does make the procedure more technically demanding
and may obviate the advantages of vesicoscopic repair. Preoperative bladder volume was not utilized
to evaluate inclusion criteria for surgical consideration. Failed injection therapy does make dissection
more complicated but should not be considered a contraindication.


## 2.2. Surgical Technique

Positioning
The
procedure is performed with the child in the dorsal lithotomy position with the
abdomen and perineum within the sterile field (Figure1). Urethral access is
needed at various times during the procedure. Due to the extended length of the
procedure, careful positioning and padding of the legs is needed to prevent
nerve palsy.
The
surgeon typically stands on the patient’s left side with the monitor positioned
over the right leg. The assistant, that is, camera holder, stands on the
patient’s right looking at a monitor positioned over the left leg. The scrub
nurse typically stands between the legs.Patient is placed in dorsal lithotomy position
with the surgeon standing to the patient’s left looking at a monitor over the
right leg.
(a)(b)Bladder Wall Fixation and Port Placement
After
positioning the patient, using a pediatric cystocope rigid cystourethroscopy is
performed using a 30-degree lens during the fixation of the bladder wall. Fixation of the bladder to the anterior
abdominal wall is critical for several reasons. Firstly, it can be difficult to
push a port through fascia and bladder wall. Fixation of the bladder will
create enough resistance to allow ports to be more easily introduced. Secondly,
in case of inadvertent removal of the port during the procedure, having the
bladder fixed to the abdominal wall will maintain the relationship between the
skin incision and the entry site within the bladder permitting replacement of
the port. Pneumovesicum is created using CO2 introduced through the irrigation
port of the cystoscope at maximal pressures of 10–15 mm Hg. Once the bladder is maximally
distended, under cystoscopic guidance the dome and lateral walls of the bladder
are fixed to the abdominal wall. The present technique for placement of the
fixation sutures is adapted from a report on percutaneous internal ring
suturing, a method for percutaneously closing the patent processus vaginalis in
children with inguinal hernias or communicating hydroceles [6].
Briefly, a 2-0 PDS suture is placed through an 18 guage spinal needle. Under
cystoscopic guidance, the spinal needle is introduced into the bladder (Figure 2(a)). This will naturally push the suture into the bladder. Upon extraction of
the needle, a loop of suture, called the pulling loop, will be left in the
bladder. Through an adjacent puncture, the spinal needle is inserted into the
bladder and through the pulling loop (Figure 2(b)). One end of the suture that
formed the pulling loop is then inserted through the needle, thus placing it
through the loop (Figure  2(c)). Retracting the pulling loop out of the bladder pulls
the free end of the suture creating a through-and-through suture which can be
tied fixing the bladder to the abdominal wall (Figure 2(d)). Fixation sutures are
placed in the midline as well as the lateral walls of the bladder. A 5 mm port
is placed in the midline for the camera and two 3 mm ports placed laterally for
the working ports. These ports are placed immediately distal to the fixation
sutures in the direction of the bladder neck. It is often helpful to place a
purse string suture around the ports to further immobilize them, minimizing the
chances for inadvertent removal. For
most children, 3 mm laparoscopic instruments that are 20 cm in length are
ideal.(a) Spinal needle has pushed
suture into bladder creating pulling loop. (b) Spinal needle passed
through pulling loop via an adjacent puncture. (c) With needle through
pulling loop, one free end of the suture is passed through spinal needle and
thus the pulling loop. (d) Removal of spinal needle
results in suture being snared by pulling loop. Subsequent retraction of
pulling loop creates through-and-through suture which can then be tied fixing
bladder to abdominal wall.
(a)(b)(c)(d)Ureteral Dissection
Vesicoscopy
is performed using a 5 mm 30-degree lens. The orientation is such that the
bladder neck will be located at the 12:00 position (Figure3). Feeding tubes (3.5 Fr.) are placed per urethra, passed up
each ureter, and fixed with fine suture. Dissection is begun by using a hook electrode
at a power setting of 10 (low power) (Figure 4(a)). Lifting up on the suture holding
the feeding tube in place will create sufficient tension such that incision of
the bladder mucosa with the hook electrode will cause the bladder to fall back.
In a manner analogous to open transvesical surgery, the ureter can be mobilized
from the surrounding detrusor muscle using a combination of sharp and blunt
dissection. Extreme care must be used when transecting investing bands of
detrusor and it may be safer to divide these bands sharply as opposed to using
cautery (Figure 4(b)). This dissection is rather easy and rapid in children with
thin-walled bladders but can be quite difficult if a child has a markedly
thickened bladder wall. Dissection is
continued until enough length is gained to bring the ureter to the
contralateral side (Figure 4(c)). The posterior detrusor opening is then closed with
interrupted 4-0 polydioxanone suture. For bilateral repairs, the contralateral
ureter may then be mobilized (Figure 4(d)).
During the
procedure a suction device is needed to remove not only blood but also urine
that may accumulate at the bladder base. Some authors have left a small
urethral catheter indwelling to assist with suction but our preference is to
simply use a 3 mm suction-irrigation device through one of the working ports as
needed.Figure 3
Initial “vesicoscopic”
view of operative site in a patient that had failed prior injection therapy.(a) Initial dissection with
hook electrode at low-power setting. (b) Investing detrusor bands
divided using sharp dissection. (c) Ureter has been
mobilized such that it can reach the contralateral side with no tension. (d) View after bilateral
mobilization and closure of the posterior detrusor openings. Ureters have been
pushed back out of bladder to permit visualization of the bladder
mucosa-detrusor plane to permit creation of the submucosal tunnels.
(a)(b)(c)(d)Tunnel Creation
Cross-trigonal
tunneling is then performed with a combination of blunt and sharp dissection in
the submucosal plane (Figure5(a)). Maryland
graspers are used to elevate the mucosa and fine scissors are used to initiate
and develop the plane. The positive pressure within the bladder along with the
optics of the 30-degree lens can assist with the visualizing the appropriate
plane. The length of the tunnel created spans from the initial hiatus across to
the contralateral hiatus. After creation of the tunnel(s), the ureters may be
placed in the tunnels and passed to the other side. The ureter(s) is then fixed
in place with 5-0 polydioxanone suture (Figure 5(b)). The remaining mucosal openings
are then closed with absorbable sutures and the feeding tubes removed (Figures 5(c) and 5(d)).(a) Creation of the
submucosal tunnels started by gently lifting up on mucosa and sharp dissection
of the appropriate plane. (b) The right ureter has
been passed through the tunnel and sutured to the original hiatus on the
contralateral side. (c) Both ureters have been
transposed and sutured in place. The left mucosal opening is then closed with absorbable
suture. (d) Completed repair prior
to removing feeding tubes.
(a)(b)(c)(d)Bladder Port Closure
To
maintain the pathway through the incision into the bladder, a feeding tube is
placed through each port prior to its removal. Under cystoscopic guidance, the bladder
ports are closed using sutures placed in a manner analogous to the initial
fixation sutures. After placing the bladder port closure sutures, a foley
catheter is inserted to decompress the bladder and the fixation sutures are
removed. This allows the bladder to fall away from the abdominal wall. The
bladder port sutures are then carefully tied and the skin incisions
subsequently closed.
The
foley catheter is typically removed in 36 hours. Followup imaging included
renal ultrasonography at one month and cystography at 3 months.


## 3. Results

To
date, 103 children have undergone attempted vesicoscopic correction. Due to
poor port placement, three were converted to open repair leaving a total of 100
patients who did undergo vesicoscopic ureteral reimplantation. There were 91
girls and 12 boys with ages ranging from 13 months to 18 years. Grade of reflux
ranged from I to IV. Ten of these
children had failed injection therapy with dextranomer/hyaluronic acid.
Seventy-eight underwent bilateral repairs and 25 unilateral. Twelve of these
patients had duplex systems and underwent common sheath reimplants.To
date, 77 patients have undergone postoperative cystograms and 72/77 (94%) had
normal studies. One of these with persistent reflux developed contralateral reflux
after unilateral reimplantation. The other four occurred early in the series,
within the first 30 patients. Cystoscopy in three of these demonstrated either
small ureterovesical fistulae or an absent intramural ureter, suggestive of
ischemic injury. Subsequent modification of the ureteral dissection technique
has led to no further cases of persistent reflux in the last 47 post-operative
cystograms performed.Two
patients did develop postoperative ureteral obstruction requiring temporary
percutaneous nephrostomy tube placement. These patients had imaging studies
that suggested extrinsic compression from retrovesical urinomas. One patient
underwent reoperative ureteral reimplantation at another center and one
resolved with stent placement. One patient developed small bladder stones which
passed spontaneously. The first patient in the series, who did not have the
bladder ports closed separately, did develop a small extraperitoneal leak which
healed with bladder drainage. All subsequent cases have had bladder ports
closed with no further port site leaks.Intraoperative
complications included proximal ureteral migration of the feeding tubes in four
patients necessitating immediate ureteroscopy for retrieval. Pneumoperitoneum
occurred occasionally and was treated by intraoperative intraumbilical Veress
needle placement.


## 4. Discussion

There
is an ever increasing interest in the application of minimally invasive
techniques for surgical reconstruction. In many centers there is a wealth of
experience in the laparoscopic management of such diverse conditions such as
impalpable testes, nonfunctional kidneys, ureteropelvic junction obstruction,
and duplex anomalies. However, very few centers have attempted laparoscopic
correction of vesicoureteral reflux. There are many possible reasons for this.
First and foremost is that standard open surgical correction works so well. It
has an extremely high success rate with minimal morbidity. Furthermore,
cosmesis is not an issue as typically a small transverse suprapubic incision is
required.If
standard ureteral reimplantation is so effective with such minor morbidity, why
consider laparoscopic, or rather a vesicoscopic approach? We feel that there
may be several advantages. Firstly, we have shown in a retrospective report that
patients undergoing vesicoscopic repair have decreased analgesic requirements
compared to after open repair. Secondly, it has been our observation that parents
are often much more accepting of having definitive surgical correction for
their children if they know it will be done “laparoscopically.” Thirdly, in a
training center, vesicoscopic reimplantation can be very effective at
developing and teaching high-level surgical techniques since careful dissection
and fine suturing need to be done, and all within the confines of the
bladder.The
ultimate benefit of a surgical procedure must be decided based on a review of
the surgical success and rate of complication. After utilizing a very similar
technique, Yeung et al. demonstrated results equivalent to open ureteral
reimplantation (96% VUR resolution) in a smaller series in children. Valla et al. demonstrated success rates of
92%. Kutikov et al., detailing their
early experience, had a 93% success rate. Our present overall success rate is
at 94%. However, all of our failures occurred in the first half of our series.
Cystoscopic evaluation of the failures demonstrated evidence of possible
ischemic injury to the ureters. We subsequently modified our dissection
technique and have had no further failures in the last 47 patients tested. Thus
with experience gained and lessons learned, we think that vesicoscopic
reimplantation is essentially equivalent to open Cohen reimplantation with
regard to efficacy of correcting reflux.Ureteral
obstruction may be the most feared complication with ureteral reimplantation
and, at least with open surgery, is usually due to ischemic stricture formation
or inappropriate angulation through the detrusor neohiatus. In our series we
did have two patients with postoperative obstruction related to retrovesical
urinomas. We suspect this was due to improperly performed ureterovesical
anastamoses with leakage of urine through submucosal tunnel.Though there are
some reports on the use of a vesicoscopic approach for megaureter repair, we
have elected not to do this. Firstly, in our experience, it is very rare to
need to taper a ureter in the first place. Secondly, a carefully performed
tapered reimplantation is difficult enough and in a training institution, our
preference is to ensure that our residents and fellows can do a quality open
megaureter repair.With the
experience gained in this series, we have applied certain modifications to
improve the procedure and its outcomes. Great care during the dissection and mobilization of the affected
ureters is necessary to prevent ureteral injury. A low power setting on the hook electrode is
mandatory. As there is no fourth port
for an assistant, one has to be careful when using electrocautery that the
tissue being divided is well away from the ureter.Port placement
can be tricky. If placed too inferiorly, the ports will be right on the
orifices. If placed too cephalad, the ports may traverse the peritoneum.
Leakage of gas into the peritoneal cavity can occur and the subsequent
pneumoperitoneum can lead to collapse of the bladder and poor visibility.
Transumbilical Veress needle placement will vent the carbon dioxide and allow
the bladder to distend appropriately.Extraperitoneal
urinary leakage diagnosed after the first procedure leads to the inclusion of bladder
port closing sutures as outlined earlier. Since the application of this technique, no other port leaks were observed. Migration of the feeding tubes proximal to
the ureteral orifice was a problem encountered four times in the study. Occasionally, the suture can pull through the
ureteral orifice with traction during dissection or manipulation of the
ureter. Fixation of the feeding tube to
the ureteral orifice is mandatory to prevent migration of the tube. Occasionally, this requires stopping the
dissection to resuture the feeding tube to the distal ureter.Vesicoscopic
ureteral reimplantation is an admittedly challenging procedure. There is a
tremendous learning curve and one must exercise a great deal of dedication at
wanting to learn the procedure. Though the complication rate that we note in
our series is greater than that which may be seen in a contemporary series of
open repairs, we suspect that this is an indication of the difficulty in
learning the procedure. The adverse events that we have noted in our series are
probably due to suboptimal execution of the technique rather than the concept
of vesicoscopic reimplantation itself. Our positive experience in the last half
of the series is indicative of the fact that vesicoscopic ureteral
reimplantation is a highly effective, minimally invasive approach for the
definitive repair of primary reflux.



---

*Source: 973616-2008-11-05.xml*