Journal of Pediatric Urology (2015) 11, 88.e1e88.e6
Laparoscopic extravesical detrusorraphy, a minimally invasive treatment option for vesicoureteral reflux: A single centre experience MS Ramaiah Hospital, Bangalore, India Correspondence to: T. Javali, MS Ramaiah Medical College, Bangalore, Karnatak, India [email protected] (T. Javali) [email protected] (A. Pathade) [email protected] (H.K. Nagaraj) Keywords Vesicoureteral reflux; Laparoscopy; Extravesical detrusorraphy; Minimally invasive Received 27 April 2014 Accepted 20 January 2015 Available online 5 March 2015
Tarun Javali, Amey Pathade, H.K. Nagaraj Summary Introduction Laparoscopy in pediatric patients offers more benefits than was earlier presumed and these widely reported benefits significantly outweigh any concerns regarding the technical difficulties. Laparoscopic correction of vesicoureteral reflux aims to duplicate the excellent results of open surgery while at the same time reducing perioperative morbidity and analgesic requirements, improving cosmesis and shortening hospital stay. Objective To share our experience of laparoscopic extravesical detrusorraphy, highlight our technical modification of intraoperative minimal “atraumatic” ureteric handling of the ureter, which we hypothesize may decrease ureteral complications, and report our results. Study design This was a retrospective chart review of 76 toilettrained children (98 refluxing units), in the age group of 3e16 years, with Grade IeIV reflux, who underwent laparoscopic detrusorraphy from June 2006 to January 2014. A ureteric catheter is inserted into the refluxing ureter and is tied to the Foleys to drain into a common bag. A three port technique is used. During ureteral dissection, a vascular sling in the form of a Rumel loop is used for atraumatic handling of the ureter. A detrusor tunnel is created with hook electrocautery. A stay suture is later passed through the abdominal wall and slings around the dissected ureter, which helps in holding the ureter approximated against the mucosal trough during detrusorraphy. Detrusor fibers are approximated with 50 Vicryl. No drain is placed and the Foley and ureteric catheter(s) are removed after 24 h. Intravenous ketorolac is given every 6 h for the first 24 h. Oral paracetamol is used for analgesia after the first 24 h. Adequate bladder emptying is ensured by assessment of post void residual urine before discharge. Renal USG alone is performed 2 weeks post operatively and repeated after 3 months along with a VCUG (voiding cystourethrography). Success
was defined as absence of reflux in the follow-up VCUG done at 3 months. Results Mean operative time was 102 26.5 min for unilateral detrusorraphy and 165 18 min for bilateral extravesical detrusorraphy. The mean duration of hospital stay was 1.5 1.7 days. There was one case of urinary retention that was managed with temporary recatheterization. There were no cases of ureteral ischemia, obstruction, hematuria or bladder spasms. Surgery was successful in 97.9% of the refluxing units (96/98). In two patients with grade IV reflux, there was downgrading to grade II on VCUG done at 3 months’ follow-up. The reflux resolved at 8 and 14 months’ follow-up, respectively. Discussion Our technique of atraumatic handling of the ureter, initially with the help of a vascular sling and later with the help of a stay suture passed percutaneously through the abdominal wall, resulted in no ureteric injuries. The postoperative morbidity of this procedure is low because the bladder is not opened, the ureter is not transected, no new UVJ is created and there is no need for placement of a drain. The risk of postoperative bowel adhesions is low as the ureter is dissected out through a narrow peritoneal window, which is again extraperitonealized at the end of the procedure (see figure). The postoperative complications of gross hematuria and bladder spasms, which may be especially encountered in patients undergoing laparoscopic Cohen’s, were not seen in our case series. Conclusion Laparoscopic extravesical detrusorraphy provides a minimally invasive treatment option for treatment of unilateral/bilateral grade IeIV vesicoureteral reflux. The postoperative morbidity is low and the success rate is favorable. Our technical modification of a “vascular sling” around the ureter facilitates atraumatic ureteric handling, which may reduce distal ureteral complications like ureteral ischemia and obstruction.
http://dx.doi.org/10.1016/j.jpurol.2015.01.007 1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Laparoscopic extravesical detrusorraphy
Figure
88.e2
Figure highlighting critical steps of laparoscopic extravesical detrusorraphy.
Introduction Laparoscopy has gained a firm foothold in the armamentarium of the pediatric urologist. Laparoscopy in pediatric patients offers more benefits than was earlier presumed and these widely reported benefits significantly outweigh any concerns regarding the technical difficulties [1]. The latter have been overcome with increasing laparoscopic experience and advances in laparoscopic instrumentation and technology. Laparoscopic surgery in the management of vesicoureteral reflux (VUR) has been slow to gain acceptance primarily for two reasons: open ureteric reimplantation has very high success rate and subureteric injection of implant materials has provided an alternative less invasive option with acceptable outcomes [2]. Laparoscopic correction of vesicoureteral reflux aims to duplicate the excellent results of open surgery while at the same time reducing perioperative morbidity and analgesic requirements, improving cosmesis and shortening hospital stay [3]. The most commonly used laparoscopic techniques for VUR correction are laparoscopic transvesical Cohen reimplantation technique and laparoscopic Lich-Gregoir reimplantation (also referred to as laparoscopic detrusorraphy/ ureteric buttressing/vesiculoureteroplasty in various studies [4e6]). The objective of this article is to share our experience of laparoscopic Lich-Gregoir extravesical ureteric reimplantation, to present a technical modification that allows better handling of the ureter, and we hypothesize that it could decrease ischemia and edema.
Materials and methods We performed a retrospective chart review of 76 patients who underwent laparoscopic detrusorraphy for primary vesicoureteral reflux from June 2006 to January 2014. Table 1 depicts the demographic data and patient profile. The indications for surgery were recurrent breakthrough infections or persistent or worsening reflux as evidenced by new scars on DMSA (dimercaptosuccinic acid) scan or worsening renal function. All patients with VUR who failed conservative
treatment/medical management were offered surgical intervention in the form of open or laparoscopic correction of VUR. All consecutive patients who elected to undergo laparoscopic extravesical detrussorraphy comprised the study group. Eight patients had previous history of Deflux injection at another institute (five patients for unilateral grade III reflux and three patients for bilateral grade II reflux). All were toilet-trained children. Uroflowmetry and post void residual assessment were done in all patients. There were no cases of secondary reflux caused by neurogenic bladder; however, six children had coexisting chronic constipation that was managed conservatively with stool softeners. There were no cases of grade V reflux in our laparoscopic database because we perform open Leadbetter-Politano repair for all patients who need ureteric tailoring along with reimplantation. After induction of general anesthesia, the patient was placed in a lithotomy position and cystoscopic assessment is done to evaluate the location of the ureteral orifice, length of the posterior bladder wall available for creating the extravesical detrusor tunnel, and other incidental findings like presence of ureterocele. Special attention was paid to presence of far laterally placed ureteric orifice that would require ureteral advancement and hence preclude laparoscopic detrussorraphy. However, no such case was identified. A 3-5 Fr. ureteric catheter was inserted into the refluxing ureter(s). An appropriate size Foley catheter was
Table 1
Patient characteristics.
Total no. of patients
76
No. of patients with b/l VUR Total no. of refluxing units Age range; mean SD Male: female Grade of reflux I II III IV
22 98 3e16 years; 9.5 3.75 years 29:47 No. of refluxing units 7 24 46 21
88.e3 inserted, used for bladder filling during the course of the procedure. At the end of the procedure the ureteric catheter(s) were tied to the Foley catheter and drained into a common urobag. The Foley catheter along with the ureteric catheter was removed after 24 h. The ureteric catheter helps in intraoperative identification and dissection of the ureter and also, protects against the effects of possible ureteral edema leading to obstruction in the immediate postoperative period. The patient was then placed in a Trendelenburg position. A 10 mm incision was made in the infraumbilical fold and a 10 mm trocar was placed using Hassan’s technique, and pneumoperitoneum was created. We used the 10 mm 30 telescope through the umbilical port. Two 5 mm working ports were inserted at the midpoint of spino-umbilical line on either side. In children younger than 5 years, the 10 mm umbilical port is replaced with a 5 mm port for the 5 mm 30 telescope. The distal segment of the ureter was identified, situated between the broad ligament and bladder base in females, and the overlying peritoneum was incised. The ureter was dissected out from surrounding connective tissue, taking care to preserve the vas in male patients. Once the ureter was dissected circumferentially at one point, a vascular sling was passed around the ureter in the form of a Rumel loop (which is doubled over) and the two ends of the sling were clipped together with a metallic clip (Fig. 1). From this point onwards the ureter was not handled directly by the laparoscopic instruments, but was maneuvered with the help of the sling. This helps in dissection as well as ensuring minimal atraumatic handling of the ureter. During dissection, a generous amount of mesoureter was maintained around the ureter to avoid devascularization. The ureter was freed from the ureterovesical junction to a suitable length proximally. Attention was then shifted to the bladder. With the bladder one-third full, a detrusor tunnel was created with the help of hook electrocautery. The tunnel extended from ureterovesical junction cephalad, for a suitable length, in a 60 lateral inclination, mirroring the course of the ureter,
Figure 1 Illustration demonstrating “Rumel” loop (which is doubled over) around the ureter to facilitate ureteric handling.
T. Javali et al. which minimized causing a kink in the ureter. At the hiatus, we limited our dissection to the lateral uretrovesical attachments and preserved the medial attachments of the ureterovesical hiatus. The anatomical basis for this is based on the cadaver studies of Leissner et al. [7], who demonstrated that the main portion of the pelvic plexus is located approximately 1.5 cm dorsal and medial to the ureterovesical junction. Limited dissection at the ureterovesical hiatus along with low power cautery settings and minimal use of coagulation helps to preserve enough branches of the pelvic plexus to maintain efficient bladder emptying in the postoperative period in cases of bilateral detrusorraphy. A 5:1 ratio between the tunnel length and ureteral diameter ratio was maintained. This works out to approximately 3e4 cm in length. The tunnel was made at bladder filling of one-third capacity. Care must be taken while creating the tunnel to avoid mucosal perforations. Minute openings may be safely ignored because ureteral embedding in the tunnel along with detrusorraphy efficiently seals off the perforations and there is no need to place a drain or delay Foley catheter removal in the postoperative period. Larger openings in the bladder mucosa should be closed with 50 vicryl. At this point, the sling around the ureter was removed. Continuing with our policy of “no-touch technique” of ureteral handling, a traction suture of 3-0 silk on a straight needle was passed into the peritoneal cavity percutaneously from the anterior abdominal wall. The entry point on the abdominal wall is just cranial and lateral to the ipsilateral pubic tubercle. This suture hooked around the dissected ureter and then exited the abdomen percutaneously close to the original site of entry. This anchoring suture loop helps in holding the ureter approximated against the mucosal tunnel, which facilitates subsequent intracorporeal suturing (Fig. 2). The detrusor fibers were approximated over the ureter using interrupted sutures of 4-0 vicryl. During closure of the
Figure 2 Intraoperative picture demonstrating stay suture passed percutaneously through anterior abdominal wall. The stay suture hooks around the ureter and keeps it approximated to the mucosal tunnel, facilitating detrusorraphy.
Laparoscopic extravesical detrusorraphy detrusor tunnel, a thin bite of ureteral adventitia was included in the cranial-most suture. Hemostasis was secured and the stay suture was removed. The peritoneal opening was closed to extraperitonealize the ureter. No drain was placed and port site closure was done. The Foley catheter along with the ureteric catheter(s) were removed after 24 h. A fluid diet was started 6 h after surgery and advanced to regular diet by 24 h. Intravenous ketorolac was given every 6 h for the first 24 h. Oral paracetamol was used for analgesia after the first 24 h on an asneeded basis. Adequate bladder emptying was ensured by assessment of post void residual urine before discharge. Renal USG alone was performed 2 weeks post operatively and repeated after 3 months along with a VCUG (voiding cystourethrography). Success was defined as absence of reflux in the follow-up VCUG done at 3 months. Ethical approval was not required for this study.
Results Statistical analysis was done using SPSS software. Table 2 summarizes the intraoperative parameters and the postoperative course and complications. All the procedures were done by a single surgeon (HKN) with experience of more than 500 laparoscopic procedures in adult and pediatric urology cases. The learning curve was very short e three cases. One 4-year-old boy with bilateral reimplantation developed urinary retention following catheter removal and had to be recatheterized. This patient also had history of chronic constipation. The patient was restarted on a high fiber diet and stool softeners and was prescribed a course of alpha blockers. He voided spontaneously when
Table 2
Results.
Operative time (range) eunilateral Operative time (range) e bilateral Mean operative time e unilateral Mean operative time e bilateral Mean estimated blood loss Open conversion Significant bladder mucosal perforationa Concomitant procedures Mean duration of hospital stay Urinary retention Hematuria Bladder spasms persisting after catheter removal Postoperative febrile UTI Pain >1 day Ureteral obstruction Catheter duration > 1 day Postoperative paralytic ileus Port-site infection Reflux resolution a
78e145 min 130e210 min 102 26.5 mins 165 18 min 15 8 ml Nil 3 1 (bladder diverticulectomy) 1.5 1.7 days 1 Nil Nil Nil 3 Nil 3 1 1 96 units (97.9%)
Defined as necessitating separate closure of bladder rent.
88.e4 the catheter was removed a week later. In three patients who had significant bladder perforation, a Foley catheter was kept for 4 days. However, the ureteric catheter was removed on postoperative day 1, even in these patients. None of the patients had bladder spasm when the Foley catheters were removed. There were no cases of ureteral necrosis or intraperitoneal urine leak. One patient had postoperative paralytic ileus as a consequence of electrolyte disturbance and was managed conservatively. The ileus resolved after correction of hypokalemia. After the first 24 h i.v. analgesia was discontinued and patients were prescribed oral paracetamol on an as-needed basis. The criteria for discharge from hospital were 1) tolerating oral feeds and 2) normal voiding after catheter removal. Surgery was successful in 97.9% of the refluxing units (96/98) at the 3-month VCUG. Two patients with grade III and three patients with grade IV reflux had hydroureteronephrosis on protocol USG performed at 2-weeks’ post op. In both the grade III patients, the degree of hydroureteronephrosis was lesser compared with the preop USG, and hence they were conservatively followed up and at the VCUG performed at 3 months there was resolution of VUR and the hydroureteronephrosis. In all three patients with grade IV reflux, the degree of hydroureteronephrosis was similar to the pre-op USG and hence DTPA renogram was carried out to rule out obstruction. Once this was ruled out, these three patients were kept on regular follow-up and protocol VCUG was done at 3 months. In one of the three patients the reflux resolved at 3months’ post op. In the remaining two cases there was downgrading to grade II on VCUG done at 3-months’ followup. These patients continued on prophylactic antibiotics, and hence were conservatively monitored. These two patients with downgraded reflux had co-existing bowel dysfunction and were managed with stool softeners. The reflux resolved at 8- and 14-months’ follow-up, respectively. No additional surgical or endoscopic intervention was required in any of the patients. When follow-up VCUG showed reflux resolution, the patients were discharged from urology care and asked to follow-up with their local physician.
Discussion There are various options available for surgical correction of vesicoureteral reflux. Concerns regarding the long-term durability and success rates of injectables and the longer convalescence/hospital stay of open surgery along with poorer cosmetic results, influence families in selecting laparoscopic repair as a viable alternative middle path for management of vesicoureteral reflux. The popular techniques currently in vogue are the laparoscopic Cohen’s and laparoscopic Lich-Gregoir. The technique of endoscopic trigonoplasty, initially described by Okamura et al. [8], has been all but abandoned [9,10]. We feel that the only shortcoming of the laparoscopic Lich-Gregoir technique is its non-applicability in patients with grade V reflux, with highly tortuous megaureters, who need concomitant ureteric tailoring. The initial concerns regarding voiding dysfunction following bilateral ureteric reimplantation have been suitably addressed by technical modifications
88.e5 [11] and good results sans voiding dysfunction have been demonstrated by open [12], pure laparoscopic [13], and robotic case series [14,15]. We have adapted the technique of nerve sparing as described initially by David et al. [11]. In our report, only one patient from the 22 bilateral reimplantation cases developed urinary retention following catheter removal. The voiding dysfunction was temporary, and preexisting chronic constipation along with a minor component of dysfunction elimination syndrome (not recognized preoperatively) may have played a role, rather than denervation as a consequence of surgery. Hence bilateral laparoscopic extravesical ureteric reimplantation can no longer be considered a contraindication. One of the dreaded complications of laparoscopic extravesical ureteric reimplantation is ureteral ischemia caused by excessive handling of the ureter. This has been reported by Lakshmanan et al. [6] and Lopez et al. [16]. Various factors could be contributory to ureteral ischemia: rough handling of the ureter, aggressive or inappropriate electrosurgical dissection, over tightening of the detrusor tunnel, or a combination thereof. However, our technique of atraumatic handling of the ureter, initially with the help of a vascular sling and later with the help of a stay suture passed percutaneously through the abdominal wall, resulted in no ureteric injuries. The creation of the detrusor tunnel is technically challenging. We propose that the bladder should be one-third full during creation of the detrusor tunnel. Overdistension results in a “tense” bladder predisposing to mucosal perforation, and should be avoided. The postoperative morbidity of this procedure is low because the bladder is not opened, the ureter is not transected, no new UVJ is created, and there is no need for placement of a drain. The Foley catheter and ureteric catheter(s) (the latter, if used) can be removed after 24 h. The mean hospital stay in our series was 1.5 1.7 days. Pain persisting beyond the first postoperative day, necessitating the need for supplemental intravenous analgesia (ketorolac), was present in only three patients. These patients were the ones in whom Foley catheter duration was extended because of intraoperative bladder mucosal perforation. The need for placement of ureteric catheter(s) is debatable. Most of the series do not use a ureteric catheter or remove it immediately after the procedure. However, ureteral obstruction necessitating surgical intervention has been reported in 2e4% of cases [17]. We secure the ureteric catheter(s) to the Foley and bring out the end(s) through the drain port of the Foley, so that they empty into a common urobag. As the Foley itself is kept for 24 h, we feel that the presence of the additional ureteric catheter(s) does not add to the morbidity. The ureteric catheters protect against possible edema causing ureteral obstruction. This may be especially relevant in patients who have had previous endoscopic injection of bulking agents. We have not had a single case of ureteral obstruction in our case series, and continue to adopt this technique. The risk of postoperative bowel adhesions is low as the ureter is dissected out through a narrow peritoneal window, which is again extraperitonealized at the end of the procedure. The postoperative complications of gross hematuria and bladder spasms, which may be especially encountered in patients undergoing laparoscopic Cohen’s, were not seen in our case series.
T. Javali et al. In situ tapering of grade V refluxing ureters and nondismembered repair by the extravesical buttressing approach has been described [18]. However, for such cases the robotic platform would be of great assistance.
Conclusion Laparoscopic extravesical detrusorraphy provides a minimally invasive treatment option for treatment of unilateral/ bilateral grade IeIV vesicoureteral reflux. The postoperative morbidity is low and the success rate is favorable. Our technical modification of a “vascular sling” around the ureter facilitates atraumatic ureteric handling, which may reduce distal ureteral complications like ureteral ischemia and obstruction.
Conflict of interest None.
Funding None.
References [1] Ure BM, Bax NM, van der Zee DC. Laparoscopy in infants and children: a prospective study on feasibility and the impact on routine surgery. J Pediatr Surg 2000;35:1170e3. [2] Kirsch AJ, Perez-Brayfield M, Smith EA, Scherz HC. The modified sting procedure to correct vesicoureteral reflux: improved results with submucosal implantation within the intramural ureter. J Urol 2004;171:2413e6. [3] Riquelme M, Aranda A, Rodriguez C. Laparoscopic extravesical transperitoneal approach for vesicoureteral reflux. J Laparoendosc Adv Surg Tech A 2006;16:312e6. [4] Ehrlich RM, Gershman A, Fuchs G. Laparoscopic vesicoureteroplasty in children: initial case reports. Urology 1994;43: 255e61. [5] Janetschek G, Radmayr C, Bartsch G. Laparoscopic ureteral anti-reflux plasty reimplantation. First clinical experience. Ann Urol 1995;29:101e5. [6] Lakshmanan Y, Fung LCT. Laparoscopic extravesicular ureteral reimplantation for vesicoureteral reflux: recent technical advances. J Endourol 2000;14:589e94. [7] Leissner J, Allhoff EP, Wolff W, Feja C, Hockel M, Black P, et al. The pelvic plexus and antireflux surgery: topographical findings and clinical consequences. J Urol 2001;165:1652. [8] Okamura K, Ono Y, Yamada Y, Kato T, Tsuji Y, Ohshima S, et al. Endoscopic trigonoplasty for primary vesico ureteric reflux. Br J Urol 1995;75:390e4. [9] Okamura K, Kato N, Takamura S, Tanaka J, Nagai T, Watanabe H, et al. Trigonal splitting is a major complication of endoscopic trigonoplasty at 1-year followup. J Urol 1997; 157:1423e5. [10] Gatti JM, Cartwright PC, Hamilton BD, Snow BW. Percutaneous endoscopic trigonoplasty in children: long-term outcomes and modifications in technique. J Endourol 1999;13:581e4. [11] David S, Kelly C, Poppas DP. Nerve sparing extravesical repair of bilateral vesicoureteral reflux: description of technique and evaluation of urinary retention. J Urol 2004;172:1617e20.
Laparoscopic extravesical detrusorraphy [12] McAchran SE, Palmer JS. Bilateral extravesical ureteral reimplantation in toilet trained children: is 1-day hospitalization without urinary retention possible? J Urol 2005;174:1991e3. [13] Tsai YC, Wu CC, Yang SSD. Minilaparoscopic nerve sparing extravesical ureteral reimplantation for primary vesicoureteral reflux: a preliminary report. J Laparoendosc Adv Surg Tech 2008;18:767e70. [14] Casale P, Patel RP, Kolon TF. Nerve sparing robotic extravesical ureteral reimplantation. J Urol 2008;179:1987e90. [15] Marchini GS, Kwon Hong Y, Minnillo BJ, Diamond DA, Houck CS, Meier PM, et al. Nguyen robotic assisted laparoscopic ureteral reimplantation in children: case matched comparative study with open surgical approach. J Urol 2011;185:1870e5.
88.e6 [16] Lopez M, Varlet F. Laparoscopic extravesical transperitoneal approach following the Lich-Gregoir technique in the treatment of vesicoureteral reflux in children. J Pediatr Surg 2010; 45:806e10. [17] Heidenreich A, Ozgur E, Becker T, Haupt G. Surgical management of vesicoureteral reflux in pediatric patients. World J Urol 2004;22:96e106. [18] Agarwal MM, Singh SK, Agarwal S, Mavuduru R, Mandal AK. A novel technique of intracorporeal excisional tailoring of megaureter before laparoscopic ureteral reimplantation. Urology 2010;75:96e9.
Laparoscopic extravesical detrusorraphy, a minimally invasive treatment option for vesicoureteral reflux: A single centre experience MS Ramaiah Hospital, Bangalore, India Correspondence to: T. Javali, MS Ramaiah Medical College, Bangalore, Karnatak, India [email protected] (T. Javali) [email protected] (A. Pathade) [email protected] (H.K. Nagaraj) Keywords Vesicoureteral reflux; Laparoscopy; Extravesical detrusorraphy; Minimally invasive Received 27 April 2014 Accepted 20 January 2015 Available online 5 March 2015
Tarun Javali, Amey Pathade, H.K. Nagaraj Summary Introduction Laparoscopy in pediatric patients offers more benefits than was earlier presumed and these widely reported benefits significantly outweigh any concerns regarding the technical difficulties. Laparoscopic correction of vesicoureteral reflux aims to duplicate the excellent results of open surgery while at the same time reducing perioperative morbidity and analgesic requirements, improving cosmesis and shortening hospital stay. Objective To share our experience of laparoscopic extravesical detrusorraphy, highlight our technical modification of intraoperative minimal “atraumatic” ureteric handling of the ureter, which we hypothesize may decrease ureteral complications, and report our results. Study design This was a retrospective chart review of 76 toilettrained children (98 refluxing units), in the age group of 3e16 years, with Grade IeIV reflux, who underwent laparoscopic detrusorraphy from June 2006 to January 2014. A ureteric catheter is inserted into the refluxing ureter and is tied to the Foleys to drain into a common bag. A three port technique is used. During ureteral dissection, a vascular sling in the form of a Rumel loop is used for atraumatic handling of the ureter. A detrusor tunnel is created with hook electrocautery. A stay suture is later passed through the abdominal wall and slings around the dissected ureter, which helps in holding the ureter approximated against the mucosal trough during detrusorraphy. Detrusor fibers are approximated with 50 Vicryl. No drain is placed and the Foley and ureteric catheter(s) are removed after 24 h. Intravenous ketorolac is given every 6 h for the first 24 h. Oral paracetamol is used for analgesia after the first 24 h. Adequate bladder emptying is ensured by assessment of post void residual urine before discharge. Renal USG alone is performed 2 weeks post operatively and repeated after 3 months along with a VCUG (voiding cystourethrography). Success
was defined as absence of reflux in the follow-up VCUG done at 3 months. Results Mean operative time was 102 26.5 min for unilateral detrusorraphy and 165 18 min for bilateral extravesical detrusorraphy. The mean duration of hospital stay was 1.5 1.7 days. There was one case of urinary retention that was managed with temporary recatheterization. There were no cases of ureteral ischemia, obstruction, hematuria or bladder spasms. Surgery was successful in 97.9% of the refluxing units (96/98). In two patients with grade IV reflux, there was downgrading to grade II on VCUG done at 3 months’ follow-up. The reflux resolved at 8 and 14 months’ follow-up, respectively. Discussion Our technique of atraumatic handling of the ureter, initially with the help of a vascular sling and later with the help of a stay suture passed percutaneously through the abdominal wall, resulted in no ureteric injuries. The postoperative morbidity of this procedure is low because the bladder is not opened, the ureter is not transected, no new UVJ is created and there is no need for placement of a drain. The risk of postoperative bowel adhesions is low as the ureter is dissected out through a narrow peritoneal window, which is again extraperitonealized at the end of the procedure (see figure). The postoperative complications of gross hematuria and bladder spasms, which may be especially encountered in patients undergoing laparoscopic Cohen’s, were not seen in our case series. Conclusion Laparoscopic extravesical detrusorraphy provides a minimally invasive treatment option for treatment of unilateral/bilateral grade IeIV vesicoureteral reflux. The postoperative morbidity is low and the success rate is favorable. Our technical modification of a “vascular sling” around the ureter facilitates atraumatic ureteric handling, which may reduce distal ureteral complications like ureteral ischemia and obstruction.
http://dx.doi.org/10.1016/j.jpurol.2015.01.007 1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Laparoscopic extravesical detrusorraphy
Figure
88.e2
Figure highlighting critical steps of laparoscopic extravesical detrusorraphy.
Introduction Laparoscopy has gained a firm foothold in the armamentarium of the pediatric urologist. Laparoscopy in pediatric patients offers more benefits than was earlier presumed and these widely reported benefits significantly outweigh any concerns regarding the technical difficulties [1]. The latter have been overcome with increasing laparoscopic experience and advances in laparoscopic instrumentation and technology. Laparoscopic surgery in the management of vesicoureteral reflux (VUR) has been slow to gain acceptance primarily for two reasons: open ureteric reimplantation has very high success rate and subureteric injection of implant materials has provided an alternative less invasive option with acceptable outcomes [2]. Laparoscopic correction of vesicoureteral reflux aims to duplicate the excellent results of open surgery while at the same time reducing perioperative morbidity and analgesic requirements, improving cosmesis and shortening hospital stay [3]. The most commonly used laparoscopic techniques for VUR correction are laparoscopic transvesical Cohen reimplantation technique and laparoscopic Lich-Gregoir reimplantation (also referred to as laparoscopic detrusorraphy/ ureteric buttressing/vesiculoureteroplasty in various studies [4e6]). The objective of this article is to share our experience of laparoscopic Lich-Gregoir extravesical ureteric reimplantation, to present a technical modification that allows better handling of the ureter, and we hypothesize that it could decrease ischemia and edema.
Materials and methods We performed a retrospective chart review of 76 patients who underwent laparoscopic detrusorraphy for primary vesicoureteral reflux from June 2006 to January 2014. Table 1 depicts the demographic data and patient profile. The indications for surgery were recurrent breakthrough infections or persistent or worsening reflux as evidenced by new scars on DMSA (dimercaptosuccinic acid) scan or worsening renal function. All patients with VUR who failed conservative
treatment/medical management were offered surgical intervention in the form of open or laparoscopic correction of VUR. All consecutive patients who elected to undergo laparoscopic extravesical detrussorraphy comprised the study group. Eight patients had previous history of Deflux injection at another institute (five patients for unilateral grade III reflux and three patients for bilateral grade II reflux). All were toilet-trained children. Uroflowmetry and post void residual assessment were done in all patients. There were no cases of secondary reflux caused by neurogenic bladder; however, six children had coexisting chronic constipation that was managed conservatively with stool softeners. There were no cases of grade V reflux in our laparoscopic database because we perform open Leadbetter-Politano repair for all patients who need ureteric tailoring along with reimplantation. After induction of general anesthesia, the patient was placed in a lithotomy position and cystoscopic assessment is done to evaluate the location of the ureteral orifice, length of the posterior bladder wall available for creating the extravesical detrusor tunnel, and other incidental findings like presence of ureterocele. Special attention was paid to presence of far laterally placed ureteric orifice that would require ureteral advancement and hence preclude laparoscopic detrussorraphy. However, no such case was identified. A 3-5 Fr. ureteric catheter was inserted into the refluxing ureter(s). An appropriate size Foley catheter was
Table 1
Patient characteristics.
Total no. of patients
76
No. of patients with b/l VUR Total no. of refluxing units Age range; mean SD Male: female Grade of reflux I II III IV
22 98 3e16 years; 9.5 3.75 years 29:47 No. of refluxing units 7 24 46 21
88.e3 inserted, used for bladder filling during the course of the procedure. At the end of the procedure the ureteric catheter(s) were tied to the Foley catheter and drained into a common urobag. The Foley catheter along with the ureteric catheter was removed after 24 h. The ureteric catheter helps in intraoperative identification and dissection of the ureter and also, protects against the effects of possible ureteral edema leading to obstruction in the immediate postoperative period. The patient was then placed in a Trendelenburg position. A 10 mm incision was made in the infraumbilical fold and a 10 mm trocar was placed using Hassan’s technique, and pneumoperitoneum was created. We used the 10 mm 30 telescope through the umbilical port. Two 5 mm working ports were inserted at the midpoint of spino-umbilical line on either side. In children younger than 5 years, the 10 mm umbilical port is replaced with a 5 mm port for the 5 mm 30 telescope. The distal segment of the ureter was identified, situated between the broad ligament and bladder base in females, and the overlying peritoneum was incised. The ureter was dissected out from surrounding connective tissue, taking care to preserve the vas in male patients. Once the ureter was dissected circumferentially at one point, a vascular sling was passed around the ureter in the form of a Rumel loop (which is doubled over) and the two ends of the sling were clipped together with a metallic clip (Fig. 1). From this point onwards the ureter was not handled directly by the laparoscopic instruments, but was maneuvered with the help of the sling. This helps in dissection as well as ensuring minimal atraumatic handling of the ureter. During dissection, a generous amount of mesoureter was maintained around the ureter to avoid devascularization. The ureter was freed from the ureterovesical junction to a suitable length proximally. Attention was then shifted to the bladder. With the bladder one-third full, a detrusor tunnel was created with the help of hook electrocautery. The tunnel extended from ureterovesical junction cephalad, for a suitable length, in a 60 lateral inclination, mirroring the course of the ureter,
Figure 1 Illustration demonstrating “Rumel” loop (which is doubled over) around the ureter to facilitate ureteric handling.
T. Javali et al. which minimized causing a kink in the ureter. At the hiatus, we limited our dissection to the lateral uretrovesical attachments and preserved the medial attachments of the ureterovesical hiatus. The anatomical basis for this is based on the cadaver studies of Leissner et al. [7], who demonstrated that the main portion of the pelvic plexus is located approximately 1.5 cm dorsal and medial to the ureterovesical junction. Limited dissection at the ureterovesical hiatus along with low power cautery settings and minimal use of coagulation helps to preserve enough branches of the pelvic plexus to maintain efficient bladder emptying in the postoperative period in cases of bilateral detrusorraphy. A 5:1 ratio between the tunnel length and ureteral diameter ratio was maintained. This works out to approximately 3e4 cm in length. The tunnel was made at bladder filling of one-third capacity. Care must be taken while creating the tunnel to avoid mucosal perforations. Minute openings may be safely ignored because ureteral embedding in the tunnel along with detrusorraphy efficiently seals off the perforations and there is no need to place a drain or delay Foley catheter removal in the postoperative period. Larger openings in the bladder mucosa should be closed with 50 vicryl. At this point, the sling around the ureter was removed. Continuing with our policy of “no-touch technique” of ureteral handling, a traction suture of 3-0 silk on a straight needle was passed into the peritoneal cavity percutaneously from the anterior abdominal wall. The entry point on the abdominal wall is just cranial and lateral to the ipsilateral pubic tubercle. This suture hooked around the dissected ureter and then exited the abdomen percutaneously close to the original site of entry. This anchoring suture loop helps in holding the ureter approximated against the mucosal tunnel, which facilitates subsequent intracorporeal suturing (Fig. 2). The detrusor fibers were approximated over the ureter using interrupted sutures of 4-0 vicryl. During closure of the
Figure 2 Intraoperative picture demonstrating stay suture passed percutaneously through anterior abdominal wall. The stay suture hooks around the ureter and keeps it approximated to the mucosal tunnel, facilitating detrusorraphy.
Laparoscopic extravesical detrusorraphy detrusor tunnel, a thin bite of ureteral adventitia was included in the cranial-most suture. Hemostasis was secured and the stay suture was removed. The peritoneal opening was closed to extraperitonealize the ureter. No drain was placed and port site closure was done. The Foley catheter along with the ureteric catheter(s) were removed after 24 h. A fluid diet was started 6 h after surgery and advanced to regular diet by 24 h. Intravenous ketorolac was given every 6 h for the first 24 h. Oral paracetamol was used for analgesia after the first 24 h on an asneeded basis. Adequate bladder emptying was ensured by assessment of post void residual urine before discharge. Renal USG alone was performed 2 weeks post operatively and repeated after 3 months along with a VCUG (voiding cystourethrography). Success was defined as absence of reflux in the follow-up VCUG done at 3 months. Ethical approval was not required for this study.
Results Statistical analysis was done using SPSS software. Table 2 summarizes the intraoperative parameters and the postoperative course and complications. All the procedures were done by a single surgeon (HKN) with experience of more than 500 laparoscopic procedures in adult and pediatric urology cases. The learning curve was very short e three cases. One 4-year-old boy with bilateral reimplantation developed urinary retention following catheter removal and had to be recatheterized. This patient also had history of chronic constipation. The patient was restarted on a high fiber diet and stool softeners and was prescribed a course of alpha blockers. He voided spontaneously when
Table 2
Results.
Operative time (range) eunilateral Operative time (range) e bilateral Mean operative time e unilateral Mean operative time e bilateral Mean estimated blood loss Open conversion Significant bladder mucosal perforationa Concomitant procedures Mean duration of hospital stay Urinary retention Hematuria Bladder spasms persisting after catheter removal Postoperative febrile UTI Pain >1 day Ureteral obstruction Catheter duration > 1 day Postoperative paralytic ileus Port-site infection Reflux resolution a
78e145 min 130e210 min 102 26.5 mins 165 18 min 15 8 ml Nil 3 1 (bladder diverticulectomy) 1.5 1.7 days 1 Nil Nil Nil 3 Nil 3 1 1 96 units (97.9%)
Defined as necessitating separate closure of bladder rent.
88.e4 the catheter was removed a week later. In three patients who had significant bladder perforation, a Foley catheter was kept for 4 days. However, the ureteric catheter was removed on postoperative day 1, even in these patients. None of the patients had bladder spasm when the Foley catheters were removed. There were no cases of ureteral necrosis or intraperitoneal urine leak. One patient had postoperative paralytic ileus as a consequence of electrolyte disturbance and was managed conservatively. The ileus resolved after correction of hypokalemia. After the first 24 h i.v. analgesia was discontinued and patients were prescribed oral paracetamol on an as-needed basis. The criteria for discharge from hospital were 1) tolerating oral feeds and 2) normal voiding after catheter removal. Surgery was successful in 97.9% of the refluxing units (96/98) at the 3-month VCUG. Two patients with grade III and three patients with grade IV reflux had hydroureteronephrosis on protocol USG performed at 2-weeks’ post op. In both the grade III patients, the degree of hydroureteronephrosis was lesser compared with the preop USG, and hence they were conservatively followed up and at the VCUG performed at 3 months there was resolution of VUR and the hydroureteronephrosis. In all three patients with grade IV reflux, the degree of hydroureteronephrosis was similar to the pre-op USG and hence DTPA renogram was carried out to rule out obstruction. Once this was ruled out, these three patients were kept on regular follow-up and protocol VCUG was done at 3 months. In one of the three patients the reflux resolved at 3months’ post op. In the remaining two cases there was downgrading to grade II on VCUG done at 3-months’ followup. These patients continued on prophylactic antibiotics, and hence were conservatively monitored. These two patients with downgraded reflux had co-existing bowel dysfunction and were managed with stool softeners. The reflux resolved at 8- and 14-months’ follow-up, respectively. No additional surgical or endoscopic intervention was required in any of the patients. When follow-up VCUG showed reflux resolution, the patients were discharged from urology care and asked to follow-up with their local physician.
Discussion There are various options available for surgical correction of vesicoureteral reflux. Concerns regarding the long-term durability and success rates of injectables and the longer convalescence/hospital stay of open surgery along with poorer cosmetic results, influence families in selecting laparoscopic repair as a viable alternative middle path for management of vesicoureteral reflux. The popular techniques currently in vogue are the laparoscopic Cohen’s and laparoscopic Lich-Gregoir. The technique of endoscopic trigonoplasty, initially described by Okamura et al. [8], has been all but abandoned [9,10]. We feel that the only shortcoming of the laparoscopic Lich-Gregoir technique is its non-applicability in patients with grade V reflux, with highly tortuous megaureters, who need concomitant ureteric tailoring. The initial concerns regarding voiding dysfunction following bilateral ureteric reimplantation have been suitably addressed by technical modifications
88.e5 [11] and good results sans voiding dysfunction have been demonstrated by open [12], pure laparoscopic [13], and robotic case series [14,15]. We have adapted the technique of nerve sparing as described initially by David et al. [11]. In our report, only one patient from the 22 bilateral reimplantation cases developed urinary retention following catheter removal. The voiding dysfunction was temporary, and preexisting chronic constipation along with a minor component of dysfunction elimination syndrome (not recognized preoperatively) may have played a role, rather than denervation as a consequence of surgery. Hence bilateral laparoscopic extravesical ureteric reimplantation can no longer be considered a contraindication. One of the dreaded complications of laparoscopic extravesical ureteric reimplantation is ureteral ischemia caused by excessive handling of the ureter. This has been reported by Lakshmanan et al. [6] and Lopez et al. [16]. Various factors could be contributory to ureteral ischemia: rough handling of the ureter, aggressive or inappropriate electrosurgical dissection, over tightening of the detrusor tunnel, or a combination thereof. However, our technique of atraumatic handling of the ureter, initially with the help of a vascular sling and later with the help of a stay suture passed percutaneously through the abdominal wall, resulted in no ureteric injuries. The creation of the detrusor tunnel is technically challenging. We propose that the bladder should be one-third full during creation of the detrusor tunnel. Overdistension results in a “tense” bladder predisposing to mucosal perforation, and should be avoided. The postoperative morbidity of this procedure is low because the bladder is not opened, the ureter is not transected, no new UVJ is created, and there is no need for placement of a drain. The Foley catheter and ureteric catheter(s) (the latter, if used) can be removed after 24 h. The mean hospital stay in our series was 1.5 1.7 days. Pain persisting beyond the first postoperative day, necessitating the need for supplemental intravenous analgesia (ketorolac), was present in only three patients. These patients were the ones in whom Foley catheter duration was extended because of intraoperative bladder mucosal perforation. The need for placement of ureteric catheter(s) is debatable. Most of the series do not use a ureteric catheter or remove it immediately after the procedure. However, ureteral obstruction necessitating surgical intervention has been reported in 2e4% of cases [17]. We secure the ureteric catheter(s) to the Foley and bring out the end(s) through the drain port of the Foley, so that they empty into a common urobag. As the Foley itself is kept for 24 h, we feel that the presence of the additional ureteric catheter(s) does not add to the morbidity. The ureteric catheters protect against possible edema causing ureteral obstruction. This may be especially relevant in patients who have had previous endoscopic injection of bulking agents. We have not had a single case of ureteral obstruction in our case series, and continue to adopt this technique. The risk of postoperative bowel adhesions is low as the ureter is dissected out through a narrow peritoneal window, which is again extraperitonealized at the end of the procedure. The postoperative complications of gross hematuria and bladder spasms, which may be especially encountered in patients undergoing laparoscopic Cohen’s, were not seen in our case series.
T. Javali et al. In situ tapering of grade V refluxing ureters and nondismembered repair by the extravesical buttressing approach has been described [18]. However, for such cases the robotic platform would be of great assistance.
Conclusion Laparoscopic extravesical detrusorraphy provides a minimally invasive treatment option for treatment of unilateral/ bilateral grade IeIV vesicoureteral reflux. The postoperative morbidity is low and the success rate is favorable. Our technical modification of a “vascular sling” around the ureter facilitates atraumatic ureteric handling, which may reduce distal ureteral complications like ureteral ischemia and obstruction.
Conflict of interest None.
Funding None.
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