UroToday - A study by Dr. John-Paul Capolicchio from Montreal evaluated laparoscopic extravesical ureteral reimplantation defining a technique for this type of procedure. His study included a total of 20 children between the ages of 4 to 15 years who underwent laparoscopic extravesical transperitoneal ureteral reimplantation. 75% of the patients were girls with 11 of those cases bilateral. All the cases were diagnosed with reflux after a urinary tract infection. The indication for surgery was breakthrough infection in 18 of the 20 patients and persistent high-grade reflux in 2 of the 20 patients.

The reflux ranged from Grade II to Grade IV, with only one case of unilateral Grade II that failed injection therapy. He described the technique to be a transperitoneal retrovesical approach. The peritoneum is incised between the bladder and the uterus in girls and the bladder and the vas deferens in boys. One caveat that he stated is the importance of measuring the extravesical tunnel utilizing a ureteral catheter as a ruler. He did state that the peritoneal envelope is opened caudal to the fallopian or vas deferens, and he divided around ligament. He did not mention the uterine artery, which is always present in the girls, and should be preserved.

He performed VCUG studies in all his patients with the resolution of reflux in 18 out of the 20 cases. Two of the patients' families refused postoperative VCUG's and one other patient was lost to follow-up. One patient developed new contralateral Grade II vesicoureteral reflux. Three of his cases were converted to open surgery. His first two cases had been converted to open surgery because they were taking longer than four hours to complete. The second case was converted to open surgery secondary to a hypertrophy detrusor muscle making the dissection difficult. He reported that his first five cases, four of which were bilateral, were considered as a learning curve. These cases were quite long but subsequent cases fell consistently below three hours for a unilateral case and below five hours for a bilateral case. He stated that his operative time was approximately two hours per ureter.

He concluded that laparoscopic extravesical ureteral implantation is another option in the surgical management of vesicoureteral. It can be performed reliably, but there is a steep learning curve. He also said that refinement in instrumentation would make this procedure much easier.

At our institution we perform both laparoscopic and robotic ureteral reimplantations, both in the vesicoscopic and extravesical manner. Our recent publication in the Journal of Urology in May 2008 showed a nerve sparing robotic extravesical ureteral reimplantation. We have had a number of patients for whom outcomes were extremely positive. Only one of our patients had a breakthrough urinary tract infection that required Deflux injection after surgery. We were able to visualize the pelvic plexus in every case. We currently have over 100 reimplant patients and have been able to identify this neurovascular bundle going towards the trigone just caudad and posterior to the ureter (this was not described by Dr. Capolicchio). In the beginning we had a quite a hard time seeing them laparoscopically as well. However, with robotic implementation we were able to visualize it on each and every procedure.

I feel that minimally invasive surgery will play a role in the treatment of vesicoureteral reflux. It does decrease morbidity as patients and their parents describe less bladder spasms experienced by the children in the postoperative healing. This is anecdotal and we are currently evaluating outcomes with the quality of life studies in outpatient cohorts.

Capolicchio JP
Adv Urol. 2008; 2008: 567980
doi:10.1155/2008/567980

UroToday Medical Editor Pasquale Casale, MD

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