Journal of Pediatric Urology (2015) 11, 45e46
Video bank
Robot-assisted anterior wall extravesical ureteral reimplantation Jason P. Joseph a, Mohan S. Gundeti b,1 a
University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA
b
Center for Pediatric Robotic and Minimal Invasive Surgery, Department of Surgery, Division of Urology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Avenue, MC 7122, Chicago, IL 60637, USA Correspondence to: J.P. Joseph, Tel.: þ1 773 702 6150 [email protected] (J.P. Joseph) [email protected] (M.S. Gundeti) Keywords Robotic; Ureteral reimplantation; Anterior wall reimplant; Extravesical; Ureteroneocystotomy; Ureter Received 22 September 2014 Accepted 30 September 2014 Available online 7 February 2015
1
Summary Introduction Here we describe our technique for robot-assisted, extravesical, anterior wall ureteral reimplantation for select patients with obstructive megaureter or high grade VUR with paraureteral diverticulum. We performed anterior wall reimplantation, extrapolating our experience with anterior wall appendicovesicostomy [Famakinwa et al., Eur Urol 2013;64(5):831e6] Methods We applied this technique at our institution for a total of 6 patients: 4 pediatric, 2 adult. Amongst our pediatric patients, 3 underwent surgery for obstructive megaureter, and 1 for a paraureteral bladder diverticulum with high grade VUR. Our 2
Technique After induction of anesthesia, the patient is placed in low lithotomy with pressure points carefully padded. Cystoscopy is performed and a double-J ureteral stent is placed. Stent placement is helpful in delineation of the ureter, ureteral spatulation, and for the postoperative period. Next, a 12-mm infraumbilical camera port is placed using the Hassan technique. 8-mm robotic ports are placed in the midclavicular line bilaterally, and a 5-mm assistant port is placed in the ipsilateral hypochondriac region [1]. The robot is docked between the legs, and instruments are loaded under vision to avoid injury to intra-abdominal organs. The ureter is identified at the level of the iliac bifurcation and mobilized distally to the vas deferens or uterine artery. Umbilical tape is passed around the ureter to avoid compromise to adventitial vasculature from excessive direct manipulation. Ureteral mobilization proceeds distally to the ureterovesical junc-
adult patients opted for surgery in the setting of distal ureteral strictures. To avoid ureteral kinking, we perform detrusorotomy in alignment with the ureter, and take care to avoid ureteral laxity during reimplantation. Results Following surgery, each of our 6 patients continues to remain without evidence of obstruction, including ureteral kinking, with follow-up ranging from 3 months to 5 years. No procedural-related complications have been noted to date. Conclusion We have found this approach to be technically straightforward, avoiding intravesical dissection and associated morbidity of bladder spasm, while achieving functional outcomes.
tion (UVJ), staying in close proximity to the ureter to avoid damage to the neurovascular bundle [2]. Just proximal to the UVJ, the anterior wall of the ureter is incised and detached from the bladder. A fine attachment of the posterior ureteral wall is left intact to facilitate alignment of ureteral spatulation, and provide countertraction during spatulation and detrusorotomy. The bladder wall defect is closed with 2-0 Vicryl. In patients with paraureteral diverticula, diverticular tissue is now excised, taking care to not compromise ureteric vascularity. The intravesical portion of the stent is brought out and the distal ureter is spatulated proximally until adequate ureteral diameter is noted. The anterior bladder is mobilized and a stay-stich is placed for countertraction. Next, anterior wall detrusorotomy is performeddin ureteral alignment to prevent angulation. The submucosal tunnel is extended to 4e5 cm in length to achieve an antireflux mechanism. Detrusor flaps are well-elevated from the
Tel.: þ1 773 702 6150.
http://dx.doi.org/10.1016/j.jpurol.2014.09.002 1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
46 overlying mucosa to ensure the tunnel diameter is able to accommodate the dilated, spatulated ureter. At this point the ureter is completely detached, and attention is directed to the ureterovesical anastomosis. 50 PDS suture is placed in the crotch of the spatulated ureter and through the bladder mucosa just proximal to the anastomosis site. Next, the bladder mucosa at the anastomosis site is incised. The distal coil of the stent is passed into the bladder, and a second suture is placed to approximate the apex of this hiatus to the distal margin of the ureter. Completing the ureterovesical anastomosis, this suture is run in continuous fashion posteriorly, while the initially placed suture is run anteriorly. Finally, the detrusor flaps are closed with 3-0 Vicryl in continuous fashion so as to create a continence mechanism. Ureteral adventia is incorporated in this suture line to minimize ureteral tension and risk of slippage. The ureteral stent is left in place for 2e4 weeks. In patients with VUR, post-operative VCUG is used for evaluation of the upper tract and drainage, while in patients with obstructive megaureter, we use ultrasound and/or MAG-3 renal scan.
J.P. Joseph, M.S. Gundeti
Conclusion This technique prevents the intravesical dissection and associated morbidity of bladder spasm while achieving functional outcomes.
Appendix A. Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jpurol.2014.09.002.
References [1] Dangle PP, Shah A, Gundeti MS. Robot-assisted laparoscopic ureteric reimplantation: extravesical technique. BJU Int 2014. http://dx.doi.org/10.1111/bju.12813. [2] Dangle PP, Razmaria AA, Towle VL, Frim DM, Gundeti MS. Is pelvic plexus nerve documentation feasible during robotic assisted laparoscopic ureteral reimplantation with extravesical approach? J Pediatr Urol 2012. http://dx.doi.org/10.1016/j.jpurol.2012. 10.018.
Video bank
Robot-assisted anterior wall extravesical ureteral reimplantation Jason P. Joseph a, Mohan S. Gundeti b,1 a
University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA
b
Center for Pediatric Robotic and Minimal Invasive Surgery, Department of Surgery, Division of Urology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Avenue, MC 7122, Chicago, IL 60637, USA Correspondence to: J.P. Joseph, Tel.: þ1 773 702 6150 [email protected] (J.P. Joseph) [email protected] (M.S. Gundeti) Keywords Robotic; Ureteral reimplantation; Anterior wall reimplant; Extravesical; Ureteroneocystotomy; Ureter Received 22 September 2014 Accepted 30 September 2014 Available online 7 February 2015
1
Summary Introduction Here we describe our technique for robot-assisted, extravesical, anterior wall ureteral reimplantation for select patients with obstructive megaureter or high grade VUR with paraureteral diverticulum. We performed anterior wall reimplantation, extrapolating our experience with anterior wall appendicovesicostomy [Famakinwa et al., Eur Urol 2013;64(5):831e6] Methods We applied this technique at our institution for a total of 6 patients: 4 pediatric, 2 adult. Amongst our pediatric patients, 3 underwent surgery for obstructive megaureter, and 1 for a paraureteral bladder diverticulum with high grade VUR. Our 2
Technique After induction of anesthesia, the patient is placed in low lithotomy with pressure points carefully padded. Cystoscopy is performed and a double-J ureteral stent is placed. Stent placement is helpful in delineation of the ureter, ureteral spatulation, and for the postoperative period. Next, a 12-mm infraumbilical camera port is placed using the Hassan technique. 8-mm robotic ports are placed in the midclavicular line bilaterally, and a 5-mm assistant port is placed in the ipsilateral hypochondriac region [1]. The robot is docked between the legs, and instruments are loaded under vision to avoid injury to intra-abdominal organs. The ureter is identified at the level of the iliac bifurcation and mobilized distally to the vas deferens or uterine artery. Umbilical tape is passed around the ureter to avoid compromise to adventitial vasculature from excessive direct manipulation. Ureteral mobilization proceeds distally to the ureterovesical junc-
adult patients opted for surgery in the setting of distal ureteral strictures. To avoid ureteral kinking, we perform detrusorotomy in alignment with the ureter, and take care to avoid ureteral laxity during reimplantation. Results Following surgery, each of our 6 patients continues to remain without evidence of obstruction, including ureteral kinking, with follow-up ranging from 3 months to 5 years. No procedural-related complications have been noted to date. Conclusion We have found this approach to be technically straightforward, avoiding intravesical dissection and associated morbidity of bladder spasm, while achieving functional outcomes.
tion (UVJ), staying in close proximity to the ureter to avoid damage to the neurovascular bundle [2]. Just proximal to the UVJ, the anterior wall of the ureter is incised and detached from the bladder. A fine attachment of the posterior ureteral wall is left intact to facilitate alignment of ureteral spatulation, and provide countertraction during spatulation and detrusorotomy. The bladder wall defect is closed with 2-0 Vicryl. In patients with paraureteral diverticula, diverticular tissue is now excised, taking care to not compromise ureteric vascularity. The intravesical portion of the stent is brought out and the distal ureter is spatulated proximally until adequate ureteral diameter is noted. The anterior bladder is mobilized and a stay-stich is placed for countertraction. Next, anterior wall detrusorotomy is performeddin ureteral alignment to prevent angulation. The submucosal tunnel is extended to 4e5 cm in length to achieve an antireflux mechanism. Detrusor flaps are well-elevated from the
Tel.: þ1 773 702 6150.
http://dx.doi.org/10.1016/j.jpurol.2014.09.002 1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
46 overlying mucosa to ensure the tunnel diameter is able to accommodate the dilated, spatulated ureter. At this point the ureter is completely detached, and attention is directed to the ureterovesical anastomosis. 50 PDS suture is placed in the crotch of the spatulated ureter and through the bladder mucosa just proximal to the anastomosis site. Next, the bladder mucosa at the anastomosis site is incised. The distal coil of the stent is passed into the bladder, and a second suture is placed to approximate the apex of this hiatus to the distal margin of the ureter. Completing the ureterovesical anastomosis, this suture is run in continuous fashion posteriorly, while the initially placed suture is run anteriorly. Finally, the detrusor flaps are closed with 3-0 Vicryl in continuous fashion so as to create a continence mechanism. Ureteral adventia is incorporated in this suture line to minimize ureteral tension and risk of slippage. The ureteral stent is left in place for 2e4 weeks. In patients with VUR, post-operative VCUG is used for evaluation of the upper tract and drainage, while in patients with obstructive megaureter, we use ultrasound and/or MAG-3 renal scan.
J.P. Joseph, M.S. Gundeti
Conclusion This technique prevents the intravesical dissection and associated morbidity of bladder spasm while achieving functional outcomes.
Appendix A. Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jpurol.2014.09.002.
References [1] Dangle PP, Shah A, Gundeti MS. Robot-assisted laparoscopic ureteric reimplantation: extravesical technique. BJU Int 2014. http://dx.doi.org/10.1111/bju.12813. [2] Dangle PP, Razmaria AA, Towle VL, Frim DM, Gundeti MS. Is pelvic plexus nerve documentation feasible during robotic assisted laparoscopic ureteral reimplantation with extravesical approach? J Pediatr Urol 2012. http://dx.doi.org/10.1016/j.jpurol.2012. 10.018.
