Robot-Assisted Laparoscopic Ipsilateral Ureteroureterostomyfor Ectopic Ureters in Children: Description of Technique

David A. Leavitt, M.D.,1 Aksharananda Rambachan, B.S.,1 Ken Haberman, M.D.,1

Romano DeMarco, M.D.,2 and Aseem R. Shukla, M.D.1

Abstract

Purpose: We report our experience and present our technique with the robot-assisted laparoscopic ipsilateralureteroureterostomy (IUU) in the management of ureteral duplication with ectopia in children.Patients and Methods: We reviewed our institutional experience for all patients who underwent a robot-assistedlaparoscopic IUU at the University of Minnesota Amplatz Children’s Hospital between December 2010 andOctober 2011. An intraoperative, three-port technique was used after a ureteral stent was placed into theipsilateral lower pole. Demographic information, diagnosis, operative time, hospital course, complications, andfollow-up were all evaluated.Results: Our series included four female patients and one male patient with a mean age of 61 months (6 to182 mos). All five had a diagnosis of upper pole ectopic ureters, one of which was associated with an ureterocele.Mean total operative time was 225 minutes (181 to 253 min), and mean hospital stay was 1.2 days (1–2 days).There were no intraoperative complications. In follow-up, at the time of ureteral stent removal, pyelonephritisdeveloped in one patient, but all patients had resolution of their presenting symptoms including urinary tractinfections and incontinence. A significant reduction in upper pole hydronephrosis was seen in all patients.Conclusions: Our experience indicates that robot-assisted laparoscopic IUU is safe and effective in the man-agement of ureteral duplication anomalies in children.

Introduction

Various methods for management of ureteral dupli-cation anomalies are established in the literature. In cases

with adequate upper pole function, preservation of this moi-ety is preferred. Ureteral reimplantation, ureteropyelostomy,and ureteroureterostomy have all been described as recon-structive alternatives. In the last 10 years, expert laparoscopistshave shown that performing these complex reconstructions,including ipsilateral ureteroureterostomy (IUU), in a mini-mally invasive fashion is feasible and offers certain advan-tages.1–4 More recently, the daVinci surgical robot has beenused to aid in complex pediatric genitourinary reconstructions,including ureteroureterostomy.5,6

There are a paucity of pediatric reports on robot-assistedlaparoscopic management of ureteral duplication with IUU.We illustrate and evaluate our technique.7

Patients and Methods

We performed an Institutional Review Board approved,retrospective chart review of all patients who underwent ro-bot-assisted laparoscopic IUU by one surgeon (AS) between

December 2010 and October 2011 at the University of Min-nesota Amplatz Children’s Hospital. In total, five patients,four female and one male, were identified. Patient 1, the oldestpatient of the series, had already had a CT scan of her abdo-men and pelvis at the time she was referred to our institution.The other four patients underwent preoperative investigationwith renal ultrasonography and voiding cystourethrography.Upper pole renal function was evaluated with technetium-99m mercaptoacetyltriglycine diuretic renography or mag-netic resonance urography. No patient had evidence ofvesicoureteral reflux into the duplicated upper pole moiety.Patient 3 had a diagnosis of ectopic ureterocele that was notseparately incised before the operation.

All patients were placed in the low lithotomy position. Webegan by performing cystoscopy, retrograde pyelography ofthe lower pole system, and placement of an appropriatelysized indwelling Double-J ureteral stent into the lower poleureter. The stent aids in the identification and mobilization ofthe ureter, while also serving as a scaffold during creation ofthe anastomosis. Postoperatively, the stent was intended toprotect the anastomosis during initial recovery and reduce thechance of anastomotic leak.

1Division of Pediatric Urology University of Minnesota Amplatz Children’s Hospital, Minneapolis, Minnesota.2Departments of Surgery and Pediatrics, University of South Dakota, Sioux Falls, South Dakota.

JOURNAL OF ENDOUROLOGYVolume 26, Number 10, October 2012ª Mary Ann Liebert, Inc.Pp. 1279–1283DOI: 10.1089/end.2012.0041

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A urethral Foley catheter was placed, followed by insertionof the robotic camera and arm trocars (Fig. 1). Initial place-ment of the camera port was midline infraumbilical by amodified Hasson technique with placement of a Veress needlethrough a small fascial incision. Once pneumoperitoneum to

12 mm Hg was achieved, a blunt tip 8-mm or 12-mm cameratrocar was placed infraumbilically. Two 5-mm robot armports were then placed under direct vision. The arm port ip-silateral to the site of repair was positioned just lateral to therectus belly approximately 1 cm inferior to the midline cameraport. The arm port contralateral to the site of repair was po-sitioned just lateral to the rectus belly at the level of the an-terior superior iliac spine. The patient was then placed in theTrendelenburg position, and the robot was docked betweenthe legs.

We chose to perform our mobilization and anastomosis atthe level of the distal ureter, where it crosses the iliac vessels.At this location, using blunt dissection and electrocautery,the duplicated right or left ureters were identified withoutmobilization of the colon. Careful dissection with the aid ofthe previously placed stent was performed with a curvedMaryland dissector and either cold scissors or a monopolarhook. Currently, there are no 5-mm monopolar scissorsavailable with the daVinci system.

The dilated ectopic ureter was mobilized as distal as pos-sible and divided using scissors (Fig. 2). An extracorporealhitch stitch was used to improve exposure during creation ofthe anastomosis by gently distracting the lower pole ureteranteriorly (Fig. 2). For small patients, a 3-0 polypropylenesuture with a straightened SH needle was used. For largerpatients, a 2-0 polypropylene on a Keith needle was used.Tension was adjusted by clamping the suture outside thebody. Proximally, the ectopic ureter was divided and spatu-lated as necessary to allow for an adequately sized anasto-mosis (Fig. 2).

Scissors were used to open an anteromedial ureterotomyon the normally inserting lower pole ureter (Fig. 3). An end toside anastomosis was created using a combination of inter-rupted and running 5-0 or 6-0 polydioxanone sutures (Fig. 3).The lateral edge was first closed using a running stitch afterwhich the posterior edge was closed under direct vision. The

FIG. 1. Schematic of robot camera (infraumbilical) and armport placement for left ipsilateral ureteroureterostomy (IUU).

FIG. 2. A left-sided robotic IUU. (A) Distal transection of ectopic upper pole ureter. (B) Passing of hitch-stitch undernormally inserting lower pole ureter. (C) Passing of hitch-stitch across abdominal wall. (D) Trimming of ectopic upper poleureter in preparation for end-to-side ureteroureterostomy.

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hitch stitch was then released, and if a surgical drain wasplaced, it was inserted through one of the 5-mm arm portsbefore port removal. The abdomen was deflated and portswere removed and examined for bleeding. The skin and portsites were closed using either 4-0 or 5-0 poliglicaprone sub-cutaneous sutures. The urethral Foley catheter, and drain ifplaced, were removed the following morning.

Results

Between December 2010 and October 2011, five robot-assisted laparoscopic IUUs were performed. Table 1 showspatient demographics and perioperative characteristics. Fourpatients were female and one was a male with a mean age of61 months (6 to 182 mos). The 6-month-old female and7-month-old male each presented with antenatal hydrone-phrosis. The 3-year-old female presented with a febrile uri-nary tract infection (UTI), and the 6-year-old female presentedwith voiding dysfunction, incontinence, and a febrile UTI. The15-year-old female presented with continuous incontinencethat had unsuccessfully been treated with a sacral neuromo-dulator device previously at another institution. All five

patients had upper pole ectopic ureters, and patient 3 also hadan associated ureterocele. The duplication anomalies wereisolated to the left in three patients, isolated to the right in onepatient, and bilateral in one patient with only the left sideshowing evidence for obstruction.

There were no intraoperative complications. Mean esti-mated blood loss was 4 mL (2–10 mL). Drains and urethralFoley catheters were removed on postoperative day 1. Meantotal operative time was 225 minutes (181–253 min). This timerepresents the total procedure time and includes cystoscopy,retrograde pyelography, stent placement, patient positioning,robot-assisted procedure, and wound closure. The meanhospital stay was 1.2 days (1–2 days).

Ureteral stents were removed between 1 and 2 weeks inchildren older than 1 year. The 6-month-old girl had her stentremoved at 4 weeks. The 7-month-old boy had his stent re-moved at 7 weeks rather than the anticipated 4 weeks be-cause of familial scheduling preferences. Patients received aninitial renal ultrasonography during a follow-up clinic visit amean of 3 months after surgery. Patient follow-up has con-tinued to present for a mean and median of 10 months (3–14months).

FIG. 3. (A) Ureterotomy in lower pole ureter. (B) Initial corner stitch of end-to-side ureteroureterostomy. (C) End-to-sideureteroureterostomy. (D) Completed ureteroureterostomy.

Table 1. Patient Demographics and Perioperative Characteristics

PatientAge

(years) Gender Presentation Diagnosis

OperativeTime(min)

EstimatedBlood

Loss (mL)

Length ofHospitalization

(days) Complications

1 15 female incontinence left duplex ectopia 224 10 1 none2 3 female febrile UTI right duplex ectopia 234 5 1 none3 6 female incontinence,

febrile UTIleft duplex ectopia,

ectopic ureterocele231 2 1 pyelonephritis

4 0.5 female antenatalhydronephrosis

left duplex ectopia 253 3 2 none

5 0.5 male antenatalhydronephrosis

Bilateral duplexectopia

181 2 1 none

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One postoperative complication with pyelonephritisoccurring 9 days after stent removal in the 6-year-old wasobserved. Her voiding dysfunction subsequently resolved,and she has not had any recurrent UTIs. On follow-up ultra-sonography, resolved or significantly improved hydrone-phrosis was noted for all children. Complete sonographicresolution of the ureterocele in patient 3 was also noted. The15-year-old experienced full resolution of her incontinenceand complete resolution of her hydronephrosis. The previ-ously placed neuromodulator was removed at the time ofureteral reconstruction.

Discussion

Minimally invasive surgical techniques are increasinglyused in all aspects of reconstructive pediatric urology.8 Robot-assisted laparoscopic ureteroureterostomy has been used intreating patients with single-system ureteral obstruction.5

Our group has reported its experience with the robot-assistedsingle-system ureteroureterostomy and pediatric pyelo-plasty.6,9 Here we report our initial experience with roboticipsilateral distal ureteroureterostomy for duplicated anoma-lies of the upper urinary tract, and we suggest that our resultsindicate that a robotic approach is feasible, safe, and providesanother treatment option in children as young as 6 months oldwith complex duplication anomalies.

Our surgical technique includes the initial placement of theureteral stent, a distal ureteroureterostomy, leaving in-situ aminimal distal ureteral stump of the transected upper poleureter, and use of a ‘‘hitch-stitch’’ to aid with ureteral expo-sure. The ureteral stent aids with identification of the lowerpole ureter, provides support during anastomosis, helpsminimize potential back-walling of the recipient ureter, andtheoretically should minimize urine leakage at the freshanastomosis.

A distal anastomosis avoids manipulation and possibleinjury of the colon, gonadal vessels, and mesentery, which arenecessary during more proximal anastomoses. Previous re-ports have shown low complication rates with incompleteremoval of refluxing distal ureteral stumps in ectopic uretersand ureteroceles, which informs our own practice of mobi-lizing the upper pole, obstructed ureter to the deep pelvis andleaving a short stump.10,11 The hitch-stitch around the recip-ient lower pole ureter helps to stabilize it and provides ampleexposure during the ureteroureterostomy.

IUU is a well-established treatment modality in the surgicalcorrection of duplex ureteral anomalies with a single ob-structed ureter.1,2,12,13 Our outcomes are comparable to openand pure laparoscopic approaches in terms of estimated bloodloss, length of stay, improvement in upper pole hydrone-phrosis, and postoperative complications.3,8,14 We experi-enced no intraoperative complications, and no case neededopen conversion.

Operative time was similar to those in other small series oflaparoscopic IUU 3,12,14; however, it was longer than that of alarger open series.15 In the open series, the mean age of 10months (2–56 mos) was significantly less than that of ourseries, which had a mean age of 61 months (6–182 mos).Compared with open surgery, the technique described here islonger because of a number of additional steps, such as cys-toscopy, retrograde stent placement, and robot docking. Weanticipate the operative times will diminish as the experience

increases for the entire clinical staff. This learning-curvephenomenon is common and expected with the dispersion ofnew surgical procedures and technologies.

Robot assistance provides many benefits for the surgeon incomparison with standard laparoscopy. The use of wristedinstrumentation, tremor abolition, and motion scaling in ro-botic surgery enhances dexterity by almost 50% comparedwith laparoscopic surgery. The use of three-dimensional vi-sualization further enhances dexterity by 10% to 15% anddecreases skills-based errors by 93%.16 Furthermore, studiesindicate that robot assistance helps reduce the learning curvefor novices in suturing compared with standard laparoscopicprocedures and enhances economy of motion for experts.17

There is also emerging evidence that the use of the da Vincirobot may help to overcome innate handedness.18 With spe-cific regard to ureteroureterostomies, robot assistance allowsfor precise sharp dissection and spatulation of the uretercompared with standard laparoscopy.19

In addition to the benefits over the standard laparoscopicprocedure, previous studies indicate that robot assistancemay offer certain advantages over open techniques. In acomparison of robot-assisted vs open pediatric pyleoplasties,the robot-assisted group had decreased hospital stay, de-creased narcotic use and operative times at our institution.20

We also found that pediatric robotic extravesical re-implantation similarly reduces length of hospitalization andnarcotic requirement compared with the open cohort.21 Inaddition, robot assistance may improve cosmesis with smallerincisions.8

Pyelonephritis developed in a single patient. Her ureteralstent was removed at home and she developed pyelonephritisthe following day. The suture dangle of the ureteral stent hadbeen left intact transurethrally and secured to the patient’sthigh, which we believe may have increased this patient’s riskfor UTI because of ascending colonization. We no longer leavethe suture dangle and remove the ureteral stent cystoscopi-cally if the stent is forecasted to be left in place for more than 7days. One of the early laparoscopic ureteroureterostomy se-ries noted two episodes of pyelonephritis in six patients (eightureteroureterostomies), and these patients also had thetransurethral string attached to the ureteral stent.3

The robotic approach is applicable to males and femalesand to a wide range of pediatric ages, from the infant to theadolescent, with encouraging results in all patients. Four ofthe five patients in this study were female, and this is con-sistent with the known female predominance of duplexanomalies with ectopia. We anticipate patients with bilateralduplication anomalies could also be safely approached withrobot assistance by placing each arm port lateral to the rectusbellies and 1 to 2 cm inferior to the umbilical camera port.Alternatively, the addition of a third robotic arm port wouldallow for independent and improved triangulation of theright and left side.

Conclusions

Our results indicate that the robot-assisted laparoscopicIUU is a safe and effective means to resolve ectopic, dupli-cated ureters in children. While many genitourinary recon-structive procedures are difficult to perform laparoscopicallybecause of the inherent complexity of intracorporeal manip-ulation with extended learning curves, robot assistance may

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shift that curve and facilitate widespread adoption of complexminimally invasive techniques.

Acknowledgment

Dr. Paul Gleich assisted with image creation and formatting.

Disclosure Statement

No competing financial interests exist.

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17. Chandra V, Nehra D, Parent R, et al. A comparison oflaparoscopic and robotic assisted suturing performance byexperts and novices. Surgery 2010;147:830–839.

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Address correspondence to:Aseem R. Shukla, M.D.

Division of Pediatric UrologyUniversity of Minnesota Amplatz Children’s Hospital

2450 Riverside AvenueEast Building MB 518

Minneapolis, MN 55454

E-mail: shukl011@umn.edu

Abbreviations UsedCT¼ computed tomography

IUU¼ ipsilateral ureteroureterostomyUTI¼urinary tract infection

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