The Robotic-assistedUreteral Reimplantation

The Evolution to a New Standard

Dana A. Weiss, MD*, Aseem R. Shukla, MD

KEYWORDS

� Robotic-assisted laparoscopic ureteral reimplantation � Extravesical � Intravesical

KEY POINTS

� Robotic-assisted laparoscopic ureteral reimplantation is a safe and efficacious alternative to openureteral reimplantation.

� Careful attention to dissection of the distal ureter and creation of the detrusor tunnel can minimizepostoperative urinary retention and bladder irritation.

� Robotic ureteral reimplantation can be used not only for vesicoureteral reflux but also for treatmentof distal ureteral obstruction.

m

INTRODUCTION: NATURE OF THE PROBLEM

Vesicoureteral reflux, the retrograde flow of urinefrom the bladder into the ureters and the renal col-lecting system, is a commonly encountered anom-aly in the pediatric urology practice. Diagnosis isgenerally renderedwith a voiding cystourethrogram(VCUG) as a result of an evaluation for prenatal dila-tion of the urinary tract, or a febrile urinary tractinfection (UTI). The incidence of vesicoureteral re-flux has been shown to be 30% to 50% in childrenpresenting with at least 1 UTI, and about 15% to41%inchildrenundergoingaworkup forantenatallydetected hydronephrosis.1,2 Although not all casesof vesicoureteral refluxneed tobe repaired, in casesof recurrent infection or persistent high-grade re-flux, surgical correction is a potential interventionto prevent pyelonephritis and renal scarring.3,4

Options for repair of vesicoureteral refluxinclude the following:

� Endoscopic injection (Deflux or other bulkingagents; Salix Pharmaceuticals, Raleigh, NC,USA )

� Open intravesical reimplantation� Open extravesical reimplantation

Division of Urology, The Children’s Hospital of PhiladelpBoulevard, Philadelphia, PA 19104, USA* Corresponding author.E-mail address: weissd1@email.chop.edu

Urol Clin N Am 42 (2015) 99–109http://dx.doi.org/10.1016/j.ucl.2014.09.0100094-0143/15/$ – see front matter � 2015 Elsevier Inc. All

� Minimally invasive (laparoscopic or robotic-assisted) intravesical reimplantation

� Minimally invasive (laparoscopic or robotic-assisted) extravesical reimplantation

Open intravesical ureteral reimplantation iswidely considered the “gold-standard” approachfor the correction of vesicoureteral reflux becauseof historical success rates that range from 95%to 99%.5,6 The limitation to these statistics, how-ever, is that some studies comprise cohortswithout a postoperative VCUG and others had var-iations in patient selection. Indeed, some morerecent studies imply a lower success rate of around93%, when a VCUG was rigorously completed3 months postoperatively.7 Despite the popularityand widespread reliance on the intraoperativeopen reimplantation, commonly encounteredpostoperative symptoms inherent to a procedurerelying on an open cystotomy—hematuria, bladderspasms, and irritative voiding symptoms—haveencouraged surgeons to explore alternatives.3,8

One such alternative has always been the open ex-travesical ureteral reimplantation. However, thistoo has drawback of requiring an open Pfannen-stiel incision and carries the risk of postoperative

hia, Wood Building, 3rd Floor, 34th and Civic Center

rights reserved. urologic.th

eclinics.co

Weiss & Shukla100

urinary retention, thought to be due to a neuro-praxia from dissection around the bladder.9,10

Indeed, the urge to avoid this neuropraxia has ledmost urologists to prefer the open extravesicalapproach only in unilateral procedures rather thanin bilateral procedures.Urology, as a specialty, has traditionally posi-

tioned itself at the intersection of technology andsurgery and has been an early adaptor of minimallyinvasive surgery, ever since the first lap nephrec-tomy in 1991. Not long after, the first pediatriclaparoscopic extravesical reimplantation wasdescribed in 1994.8,11 Following this, urologistsfurther innovated with the laparoscopic intravesi-cal Cohen cross-trigonal reimplant.12 However,because of a steep learning curve and consider-able physical strain on the surgeon—exacerbatedin smaller children—the pure laparoscopicapproach was not broadly accepted. Althoughvariations in surgical technique have been re-ported, overall, results were not as consistent asthe open technique and procedures were compli-cated by urinary fistulae and bladder leaks.3,12–17

The advent of the da Vinci Surgical System (Intu-itive Surgical, Mountain View, CA, USA) revolution-ized minimally invasive surgery. The da Vincisystem, using amaster-slave platform that is underthe control of the surgeon, carries well-known ad-vantages of 3-dimensional visualization (now inhigh definition), articulating instruments and damp-ening of tremor. The robotic-assisted laparoscopic(RAL) surgery concept has facilitated the use ofminimally invasive approaches in both adults andchildren and is in widespread use for proceduresranging from the radical prostatectomy to recon-structive urology.18 Peters and Woo14 describedthe robotic-assisted transvesicoscopic approach,where only 1 patient of 6 initial patients had acomplication of a urine leak. The inherent chal-lenges of obtaining and maintaining pneumovesi-cum, and the challenges of limited articulation ofrobotic instrumentation in the bladder, limitedpopularity of the intravesical technique. Howeverone of the earliest large series of RAL extravesicalureteral reimplantations in 2008 reported successequivalent to those generally expected by theopen technique.12 As demonstrated herein, theuse of the RAL surgery has made the repair of ves-icoureteral reflux a viable approach in comparisonwith antibiotic prophylaxis, even as the potentialadverse events aremitigated by improvedmagnifi-cation and focused dissection.9,14,19

INDICATIONS/CONTRAINDICATIONS

For vesicoureteral reflux (VUR), indications fortreatment include recurrent pyelonephritis/febrile

UTIs, worsening hydronephrosis/parenchymalthinning, worsening function on renal scan, anddesire by parents to come off of prophylactic an-tibiotics. However, the technique of RAL ureteralreimplantation (RALUR) is applicable for thecorrection of VUR and the same approach maybe used for other interventions as well. Indica-tions for RALUR also include management ofobstructed megaureters and distal ureteral stric-tures resulting in loss of function, pain, UTI, andsepsis. For these, the repair of the obstructeddistal ureter requires a dismembered reimplanta-tion to excise the narrowed ureterovesical junc-tion followed by reanastomosis of the ureter tothe bladder and creation of a nonrefluxingtunnel.20 There are very few definite contraindi-cations to RALUR—primarily lung or heart anom-alies that preclude insufflation. Even a history ofprevious abdominal surgery is only a relativecontraindication to laparoscopy—a rare occur-rence when significant adhesions preclude safeaccess to the abdominal cavity.

TECHNIQUE/PROCEDUREPreparation

Preoperative assessment is the same regardlessof whether the surgical approach will be vesico-scopic or extravesical. Appropriate imagingincluding ultrasound, VCUG, and dimercaptosuc-cinic acid (optional) should be reviewed beforesurgery. Routine preoperative laboratory testsare not required, but a urinalysis or urine cultureis recommended if the patient has been symptom-atic recently. Patient size does not limit the use ofthe robotic approach; however, for the intravesicalapproach, it is advisable that the patient be morethan 4 years of age with a bladder capacity of atleast 200 mL.21

Patient Positioning

The patient is placed supine in the low lithotomyposition on Allen stirrups, which allow for preoper-ative cystourethroscopy in the same setting, ifrequired. For smaller patients, the patient canremain supine with the legs on the table as well.The patient is secured to the bed with tapingacross the chest, with care to assure that all pres-sure points are well padded. In addition, it is rec-ommended to be careful here to ensure that thehead of the patient is turned to the side to avoidthe robotic arms hitting the endotracheal tube. Asterile preparation of the abdomen from xyphoiddown through perineum is performed, and the pa-tient is draped, so that there is access to the ure-thra for cystourethroscopy or catheter placementduring the procedure. The authors find a sketch

Robotic-assisted Ureteral Reimplantation 101

over the drape overlying the child’s head makeseveryone cognizant of where the face and tubeare during the procedure.

Approach

For all ureteral reimplantations where dismember-ment of the ureterovesical junction is foreseen, asin cases of obstructed megaureter or ureteral ste-nosis, start by performing cystoscopy with ure-teral stent placement. Some surgeons prefer toplace ureteral stents temporarily during extraves-ical ureteral reimplantation as well, so this is doneat the beginning of the procedure. Ureteral stentplacement is not standard practice for mostcases.

Intravesical Robotic-assisted UreteralReimplant: Technique

The patient is placed into a steep Trendelenbergposition at the start of the procedure. The bladderis filled with saline and the ports are placed underconstant direct cystoscopic vision. Before portplacement, 2 sutures are passed transabdominallythrough the rectus fascia and into the bladder un-der cystoscopic guidance. These sutures are usedto keep the bladder tented to the abdominal wallduring the surgery and then are used to close thebladder at the end of the operation. Initially, atransverse midline incision below the umbilicus ismade for the camera port (8.5 mm). This port ispositioned in the dome of the bladder. The 2 ro-botic working arms are placed at the edge of therectus on each side, just below the level of thecamera port. Once all ports are placed, the salineis emptied from the bladder and the bladder isfilled with CO2.

Ureteral stents are placed into the bladderthrough one of the robotic ports and thenadvanced into the ureter. Ureteral stents arethen sutured to the ureteral orifice with a monofil-ament suture. The stent and suture are then usedas a handle for manipulating the ureter duringmobilization. Just as in an open repair, the ureteris mobilized from the level of the orifice throughthe intramural region into the retroperitoneum.21

A feeding tube placed transurethrally and con-nected to suction can be used intermittently asa suctioning device and then clamped when notin use.15,22

Once the ureter is mobilized, the opening in thedetrusor is closed to prevent loss of the pneumo-vesical pressure. A submucosal tunnel is thencreated by sharp dissection with cold scissorsor it can be made by tunneling a ureteral dilator.The ureteral stent is then passed through the tun-nel first, and the ureter is pulled along in suit.

Finally, the ureteral cuff is sutured to the bladdermucosa in an interrupted fashion. Ureteral stentscan be left depending on the surgeon’spreference.

Postoperative recovery is the same as with mostminimally invasive surgery in pediatric urology. AVCUG is performed on the day after surgery torule out a bladder leak, and if negative, the Foleycatheter can be removed.21

Extravesical Robotic-assisted UreteralReimplant: Technique

After the patient has been prepared and draped inthe aforementioned manner, a Foley catheter isplaced in sterile fashion on the field and a urineculture is obtained. Intraperitoneal access is ob-tained at the umbilicus (curvilinear incision at theinferior umbilicus or vertical incision through theumbilicus.) Here, via the Veress or Hassan tech-nique, the 8.5-mm robotic port is placed. Next,the table is placed into the steep Trendelenbergposition to allow all peritoneal contents to slidecranially. Two robotic 5-mm ports are positionedbelow the level of the umbilicus in the midclavic-ular line. If performing a unilateral reimplant, thenthe ports can be skewed so that the ipsilateralport is placed more cephalad than the contralat-eral side to improve the working distance onthat side and to maximize triangulation towardthe region of interest. The authors generally usea hook on the right and a Maryland grasper onthe left; however, some surgeons prefer 8-mmports and thus can use the hot scissors on theright instead.

The dissection begins by opening the perito-neum; in female patients, dissection begins distalto the round ligament to visualize the ureter andthen proceeds proximally from there (Fig. 1). Inmale patients, the ureter is first visualized and thisis traced distally until the vas deferens is identified.The peritoneum is opened distal to the vas withcareful attention to sweep the vas away from thesurgical field to avoid injury. The ureter is dissecteddistally to the level of the ureterovesical junction,and proximally until there is good freedom ofmovement with minimal tension when lifted towardthe bladder.

The authors use a transabdominal wall hitchstitch (0 polydiaxanone (PDS II, Ethicon) on CT 1needle) placed into the bladder to provide superiortension for better visibility and handling of thebladder for the dissection and repair (Fig. 2). Thebladder is filled via the urethral catheter with 30to 50 cc saline. With hook cautery, the detrusoris incised vertically, making sure not to enter themucosa. The incision is extended all the way

Fig. 1. (A) Identification of ureter in female. (B) Opening peritoneum distal to broad ligament.

Weiss & Shukla102

down to the ureter anteriorly, but the authors donot dissect circumferentially around the ureter.The tunnel is made at a length of 4 or 5:1 of thediameter of the ureter. During the dissection, a“blue dome” of mucosa protrudes, and this en-ables visualization of each individual detrusor fi-ber, because it is important to cut all detrusorfibers of bladder thoroughly. Finally, the authorsdevelop flaps of detrusor on either side that willbe used to close over the ureter (Fig. 3).Once the ureter and bladder are ready, the de-

trusorrhaphy is begun. Using 5-0 poliglecaprone(Monocryl, Ethicon, Blue Ash, OH, USA) suture(this is the authors’ preference, because it hasless memory than polydiaxonone, PDS II, Ethicon),the edges of the detrusor are approximated fromthe level of the ureteropelvic junction superiorly.After taking a stitch of the detrusor flap on oneside, these sutures are passed underneath the ure-ter to the contralateral detrusor flap to ensureadvancement of the ureter within the detrusortrough. To complete the stitch, the needle is againpassed back under the ureter to the original sideand tied there (Fig. 4). For the first 2 stitches, avery small bite of adventitia of the ureter is taken,to prevent the ureter from slipping out of the tunnel.

Fig. 2. (A) Needle of hitch stitch being passed through anbladder.

Alternatively, some surgeons prefer to affix the ure-ter to the distal end of the detrusor trough with thefirst suture pass and then close the detrusor overthe top of the ureter. The authors prefer the gradualclosure from bottom to top to assess tension atevery step. Caution here is required as taking toomuch of a bite on the ureteral adventitia can causeobstruction, and taking the ureter up too high in thetunnel can kink the ureter and cause obstruction aswell. As a last step, the hitch stitch is released andthe ureter and bladder position are assessed.Finall robotic ports are removed and the fascia

and skin of all ports are closed. The authors preferto use local anesthetic injection in individual portsites rather than a preoperative intrathecal opiateinjection because, in the authors’ experience, thelocal anesthetic has similar efficacy while avoidingpotential complications of a central block.

Complications and Management

Complications of robotic ureteral reimplant includethe following:

� Bleeding: With careful ureteral dissection,bleeding is very rare. Most often point

terior abdominal wall. (B) Placing hitch stitch through

Fi

Fig. 3. Incision of depressor, with visualization of “blue dome” (right).

Robotic-assisted Ureteral Reimplantation 103

coagulation and pressure can controlbleeding encountered during the surgery.

� Bowel injury: This can occur during intraperi-toneal access, as in any laparoscopic case.The key to this is early identification, becausemost injuries are small and can be managedby primary closure or oversewing a segment.The other area of risk is of inadvertent thermalinjury by the camera or by a robotic arm duringcoagulation. Unfortunately, most of thesehave a delayed presentation of 2 to 3 days,manifested by abdominal pain, fever, andleukocytosis. Port-site pain is the classic indi-cator of an intraperitoneal injury and man-dates a full evaluation. A high index ofsuspicion for this is necessary for diagnosis.

� Ileus: This is not uncommon postoperativelyand is usually mild in nature with self-resolution within 1 to 2 days. Focus ondecreasing narcotic use and early ambulationmay help to prevent this.

� Port-site hernia: This usually has a delayedpresentation after 2 to 3 weeks. It may presentas an asymptomatic bulge or pain at a portsite (Fig. 5). The diagnosis can be confirmedwith ultrasound, and management involvessurgical reduction and closure of the fascia.

g. 4. Detrussor closure with passage of suture needle und

This repair may be performed laparoscopi-cally with simple reduction of the omental tis-sue that is the typical herniated content. Thefascia of all 3 port sites should be closed atthe time of surgery, but this does not preventhernia in all cases.

� Ureteral obstruction: This is most often due totransient edema and can be managed expec-tantly if the patient is still making urine. In thesetting of a solitary kidney, a ureteral stentshould be left at the time of surgery. Ifobstruction does not improve or the patientbecomes anuric, urgent placement of a ure-teral stent is required.

� Ureteral injury: This can be due to aggressivedissection and devascularization of the ureteror due to an inadvertent incision in the ureter.A ureteral injury may be noticed intraopera-tively or may have a delayed presentation.Because postoperative drains are not used,abdominal distention and pain, and ileusmay be signs of injury. Laboratory values ofincreased serum creatinine (because of urineabsorption) and renal bladder ultrasound find-ings of free intra-abdominal fluid with orwithout hydronephrosis may indicate theneed for further investigation.

erneath ureter (right).

Fig. 5. Port site hernia.

Weiss & Shukla104

� Urinary retention: This is the most commoncomplication after ureteral reimplantation. Toavoid this, surgeons may consider leaving asuprapubic tube at the time of surgery in pa-tients with known dysfunctional voiding. Alter-natively, a Foley catheter can be kept forseveral days in these children to avoidreplacement. Once the Foley catheter isremoved, the child should be encouraged totimed void every 2 to 3 hours to promotebladder emptying.

Postoperative Care

Although this surgery can be performed on anoutpatient basis, most children are kept in the hos-pital for one night with a Foley catheter in place.Diet is begun immediately and advanced as toler-ated, but the child is kept on intravenous fluids un-til they are able to tolerate oral intake sufficiently.The Foley catheter is removed the next morning,and the patient can be discharged once sheis able to urinate with a residual that is less than1/2 of the total volume voided.

Follow-Up

The patient returns to clinic in 1 month with an ul-trasound. If no abnormalities are detected, pro-phylactic antibiotics are then discontinued at thatpoint. Because a pilot study by surgeons at the au-thors’ institution revealed a sufficiently high resolu-tion rate by the RALUR technique, the authors donot routinely perform a postoperative VCUG studyunless the child develops another recurrent febrileUTI.23

OUTCOMES

Table 1 displays results from a wide range ofstudies that have been performed to evaluate thesafety and efficacy of the RALUR. The studiesclearly reveal that current practice trends easilyfavor RALUR over pure laparoscopy, likely due tothe former’s benefits in increased range of motion,ease of suturing, and improved ergonomicsrendering less strain on the surgeon.Kutikov and colleagues15 reported on an expe-

rience of 27 patients undergoing the laparo-scopic transvesical ureteral reimplantation forvesicoureteral reflux (as well as an additional 5for primary obstructed megaureter). Four of the27 reflux operations had complications includingpostoperative ureteral leak and development of aureteral stricture. Three of the 4 patients who hadcomplications had small bladders, which high-lighted a key factor of bladder size that affectedoutcomes.In a direct comparison between open and

pure laparoscopic vesicoscopic ureteral reim-plants, Canon and colleagues24 retrospectivelyreviewed 52 patients who underwent vesico-scopic, and 40 who underwent open ureteral re-implantations. There were 3 complications in thevesicoscopic group compared with 0 in theopen, and resolution of VUR was only in 91%versus 97%. However, this was still an earlyexperience, and later, Valla and colleagues25 re-ported a 95% success rate in 72 vesicoscopicreimplants.With the advent of robotics to enable more com-

plex laparoscopic reconstructive procedures, thetechnology has been increasingly implemented inthe pediatric population as well. In 2008, Casaleand colleagues9 reported their experience of bilat-eral extravesical RALUR. In this series of 41 pa-tients, there were 8 patients with grade 3 VUR, 5patients with grade 4, and 5 patients with grade5 VUR. No patient experienced postoperative uri-nary retention, and there was resolution in 40 of41 (97.6%) as confirmed by postoperative VCUGstudy. In a later study, the same institution pre-sented 150 patients followed prospectively andtreated with bilateral extravesical RALUR for grade3 or higher VUR. Here, they identified no complica-tions and reported a 99.3% VUR resolution ratebased on postoperative VCUG studies.26 The au-thors think that the�10 magnification and 3D visu-alization of the robotic console aids in identifyingnerve bundles that minimize the risk of postopera-tive urinary retention.In 2011, Smith and colleagues13 presented a

comparative study of 25 RALUR matched with25 open cross-trigonal ureteral reimplantations.

Robotic-assisted Ureteral Reimplantation 105

For outcomes, a VCUG was performed for all ro-botic reimplants, while the lack of a febrile UTIwas considered success for the open group. Inthis head-to-head comparison, RALUR was foundto be safe and efficacious. They found that theopen group had statistically significantly loweroperative time, but the RALUR group had shorterlength of stay and diminished postoperative anal-gesic use. When comparing only those who hadpostoperative VCUG in each group, the roboticgroup had a 96% resolution rate, whereas theopen group resolved in 100% of cases. Of note,3 of the 8 children in the bilateral extravesical RA-LUR group did experience transient postoperativeretention.

Marchini and colleagues7 directly comparedRALUR using the vesicoscopic or extravesicalapproach, as well as pure laparoscopic extravesi-cal reimplantations. By setting up a retrospective4-way matched comparison between both openand laparoscopic intravesical and extravesical ap-proaches, the group found that operative time wassignificantly lower for both open intravesical andextravesical procedures, while hospital stay waslower in the robotic intravesical group comparedwith the open intravesical group. Both RALURgroups with extravesical approaches had thesame length of stay. There was a higher incidenceof bladder spasms in the open intravesical groupcompared with any other group, while each ofthe RALUR groups—intravesical and extravesi-cal—did see cases of urinary retention (1 intraves-ical and 2 extravesical) not seen in the opengroups. Four patients in the robotic intravesicalgroup had bladder leaks, and 2 undergoing roboticextravesical reimplants had ureteral leaks. At3-month follow-up with VCUG, 3 in the robotic in-travesical reimplant group and 4 in the open (3 inthe intravesical and 1 in the extravesical) grouphad VUR.

In a small single-surgeon experience withRALUR, Chalmers and colleagues27 presentedresults for 23 ureters with a 90.9% successrate, underscoring the importance of a suffi-ciently long tunnel. Calculating tunnel length dur-ing the transition from open to minimally invasivesurgery is technically challenging because ofthe obviously different optical dimensions andrequires careful measurement using instrumentswith known lengths as a reference, or ameasuring tape that can be inserted during theprocedure.

In a recent report, Akhavan and colleagues28

presented a retrospective experience of 78 ure-ters in 50 patients over 7 years that underwentRALUR using the extravesical approach. Mostof these repairs were done for grade 3 VUR,

and some required bilateral procedures. All pa-tients not only underwent US postoperativelybut also underwent postoperative radionuclidecystograms to assess resolution of VUR. Thiscohort had a 92.3% success rate (defined asno residual VUR). A total of 10% of patients didexperience a postoperative UTI, but none ofthese were found to have residual VUR. Allpatients developing a postoperative UTI weregirls with a history of detrusor external sphincterdyssynergia. A total of 2% of the entire groupand 4% of the bilateral RALUR group did experi-ence urinary retention even for up to 3 weeks.These patients had been identified preopera-tively as having voiding dysfunction, and supra-pubic tubes were placed preemptively at thetime of surgery. Up to 10% of patients hadcomplications including edema causing transientureteral obstruction, ileus, perinephric fluid col-lection, and ureteral injury. All obstructions andleaks were treated with ureteral stent placement.

Finally, Schomburg and colleagues23 presentedan experience of a single surgeon performing openextravesical reimplantations compared with extra-vesical RALUR. In this matched comparison of 20patients in each group, they found that the proce-dure did take longer in the robotic cohort for bothunilateral and bilateral procedures (165 min vs109 min for the unilateral, and 227 min vs134.5 min for bilateral, P<.001), but there was nodifference in duration of urethral catheterization,length of stay, postoperative retention, or persis-tent VUR. The robotic group did use fewermorphine equivalents for postoperative pain con-trol. There was no difference in complication ratesin each group.

CURRENT CONTROVERSIES/FUTURECONSIDERATIONS

Minimally invasive surgical techniques carry thenecessary burden of proving that the benefits ofimproved cosmesis and decreased analgesia arenot predicated on compromised safety or efficacy.It may be rightfully argued that the RALUR hasbeen proven as feasible, safe, and efficaciouswhile delivering the well-known benefit of mini-mally invasive surgery. The long-term durabilityand safety of the repair, which is comparable toopen repairs in the near term, await substantiation.Last, surgeons must continue to ensure that thetechnological leapfrogging does not begin tochange the indications for surgery. The technologymust be used as a tool—as a means to an endrather than use the technology as a means inand of itself.

Table 1Results from studies evaluating the safety and efficacy of the robot-assisted laparoscopic ureteral reimplantation

Study TechniquePatients (n)/Ureters (n)

Mean/MedianAge (Range), y

Mean/MedianOperative Time, h

Mean/MedianLOS (Range), d Complications Success (%)

Peters andWoo,14 2005

RALUR/IV 6/12 5/15 NA 2-4 1(urine leak) 83.3

Kutikov et al,15

2006LUR/IV 27 (54)a 5 (1.2–11) 2.8 45.7 (22–92) 3 (leak5 2, stricture5 1) (tapered

ureter)92.6

Canon et al,24

2007LUR/IVOR/IV

52 LUR/40 OR 5.7/4.0 LUR/IV3.3OR/IV1.5

LUR/IV2.1OR/IV2.0

3 (LUR): (urinary leak 5 1,stones 5 1, bilateral ureteralobstruction 5 1)

91 (LUR)/97 (OR)

Valla et al,25

2009LUR/IV 72 4.2 (0.5–14) 1.37 uni/2.17 bil 2.8 6 (2, abdominal wall hematoma,

4, converted to open)b95%

Marchini et al,7

2011RALUR/IVand EV

OR/IV andEV

RALUR19 intra20 extra

RALUR intra, 9.9RALUR extra, 8.6

RALUR intra, 3.88RALUR extra, 3.89

RALUR/IV 1.8RALUR/EV 1.7

RI, 5 (retention 51, leak, 4),RE, 4 (retention 5 2, ureteralleak 5 2), OI, 0, OE, 0c

RALUR/IV 92.2RALUR/EV 100

Open22 intra17 extra

Open intra, 8.8Open extra,6.0

Open intra, 2.46Open extra, 2.0

OR/IV2.9OR/EV1.7

OR/IV93.2OR/EV94.2

Emir et al,29

2012LUR/IV 11 (17) 6.9 (2–15) 3.61/5.1 3.8 (3–5) 0 94

Weiss

&Sh

ukla

106

Casale et al,9

2008RALUR/EV 41 (82) 3.2 (1.3–6.8) 2.33 26.1 0 97.6

Smith et al,13

2011RALUR/EVOR/IV

RALUR/EV25 (33)OR/IV25 (46)

5.8/4.2 3.08/2.75 33/51 4 (3, urinary retention, in bilateralRALUR; 1, bladder leak in OR)

RALUR/EV97OR/IV100

Kasturi et al,26

2012RALUR/EV 150 (300) 3.55 (2.25–9.25) 1.8 22.1 (18–34) 0 99.3

Chalmerset al,27 2012

RALUR/EV 17 (23) 6.23 � 3.4 2.12/2.95 1.3 0 90.9

Bayne et al,30

2012LUR/EV 98 (144) 6 (0.9–20.3) NA 1.35 4 (retention 5 3, obstruction 5 1) 95.2

Schomburget al,23 2014

RALUR/EVOR/EV

20 RALUR20 OR

6.2, RALUR/EV4.3 OR/EV

RALUR uni, 2.75RALUR bil, 3.78

RALUR/EV 1.05OR/EV1.4

RALUR, 2, OR, 7 RALUR/EV100d

OR/EV95

Open uni, 1.82Open bil, 2.23

Akhavanet al,28 2014

RALUR/EV 50 (78) 6.2 (1.9–18.0) NA 2.0 (1–6) 6 (ileus 5 2, ureteralobstruction 5 2, ureteralinjury 5 1, perinephricfluid 5 1)

92.3

Abbreviations: EV, extravesical; IV, intravesical; LUR, laparoscopic ureteral reimplant; OR, open ureteral reimplant.a Excludes surgeries in series performed for primary obstructed megaureter.b Excluded spontaneously resolving scrotal emphysema, pneumoperitoneum intraoperatively.c Excluded pain greater than 2, bladder spasms, and hematuria from complication list.d Not all RALUR had postoperative VCUG.

Robotic-a

ssistedUreteralReim

plantatio

n107

Weiss & Shukla108

SUMMARY

� RALUR is a safe and efficacious alternative toopen ureteral reimplantation.

� Careful attention to dissection of the distalureter and creation of the detrusor tunnelcan minimize postoperative urinary retentionand bladder irritation.

� Robotic ureteral reimplantation can be usednot only for vesicoureteral reflux but also fortreatment of distal ureteral obstruction.

REFERENCES

1. van Eerde AM, Meutgeert MH, de Jong TP, et al.

Vesico-ureteral reflux in children with prenatally

detected hydronephrosis: a systematic review. Ul-

trasound Obstet Gynecol 2007;29:463–9.

2. Moorthy I, Joshi N, Cook JV, et al. Antenatal hydro-

nephrosis: negative predictive value of normal post-

natal ultrasound–a 5-year study. Clin Radiol 2003;

58:964–70.

3. Trevisani LF, Nguyen HT. Current controversies in

pediatric urologic robotic surgery. Curr Opin Urol

2013;23:72–7.

4. Elder JS. Guidelines for consideration for surgical

repair of vesicoureteral reflux. Curr Opin Urol 2000;

10:579–85.

5. Skoog SJ, Peters CA, Arant BS Jr, et al. Pediatric

vesicoureteral reflux guidelines panel summary

report: clinical practice guidelines for screening sib-

lings of children with vesicoureteral reflux and neo-

nates/infants with prenatal hydronephrosis. J Urol

2010;184:1145–51.

6. McCool AC, Joseph DB. Postoperative hospitaliza-

tion of children undergoing cross-trigonal uretero-

neocystostomy. J Urol 1995;154:794–6.

7. Marchini GS, Hong YK, Minnillo BJ, et al. Robotic

assisted laparoscopic ureteral reimplantation in

children: case matched comparative study with

open surgical approach. J Urol 2011;185:

1870–5.

8. Ehrlich RM, Gershman A, Fuchs G. Laparoscopic

vesicoureteroplasty in children: initial case reports.

Urology 1994;43:255–61.

9. Casale P, Patel RP, Kolon TF. Nerve sparing robotic

extravesical ureteral reimplantation. J Urol 2008;

179:1987–9 [discussion: 90].

10. Dangle PP, Razmaria AA, Towle VL, et al. Is pelvic

plexus nerve documentation feasible during ro-

botic assisted laparoscopic ureteral reimplantation

with extravesical approach? J Pediatr Urol 2013;

9:442–7.

11. Janetschek G, Radmayr C, Bartsch G. Laparo-

scopic ureteral anti-reflux plasty reimplantation.

First clinical experience. Ann Urol (Paris) 1995;29:

101–5.

12. Gill IS, Ponsky LE, Desai M, et al. Laparoscopic

cross-trigonal Cohen ureteroneocystostomy: novel

technique. J Urol 2001;166:1811–4.

13. Smith RP, Oliver JL, Peters CA. Pediatric robotic ex-

travesical ureteral reimplantation: comparison with

open surgery. J Urol 2011;185:1876–81.

14. Peters CA, Woo R. Intravesical robotically assisted

bilateral ureteral reimplantation. J Endourol 2005;

19:618–21 [discussion: 21–2].

15. Kutikov A, Guzzo TJ, Canter DJ, et al. Initial experi-

ence with laparoscopic transvesical ureteral reim-

plantation at the Children’s Hospital of Philadelphia.

J Urol 2006;176:2222–5 [discussion: 5–6].

16. Cartwright PC, Snow BW, Mansfield JC, et al. Percu-

taneous endoscopic trigonoplasty: a minimally inva-

sive approach to correct vesicoureteral reflux. J Urol

1996;156:661–4.

17. Tsuji Y, Okamura K, Nishimura T, et al. A new endo-

scopic ureteral reimplantation for primary vesicoure-

teral reflux (endoscopic trigonoplasty II). J Urol

2003;169:1020–2.

18. Phillips EA, Wang DS. Current status of robot-

assisted laparoscopic ureteral reimplantation and

reconstruction. Curr Urol Rep 2012;13:190–4.

19. Mathews R, Carpenter M, Chesney R, et al. Contro-

versies in the management of vesicoureteral reflux:

the rationale for the RIVUR study. J Pediatr Urol

2009;5:336–41.

20. Faasse MA, Lindgren BW, Gong EM. Robot-assisted

laparoscopic ureteral reimplantation with excisional

tailoring for refluxing megaureter. J Pediatr Urol

2014. [Epub ahead of print].

21. Minnillo BJ, Marchini GS, Nguyen HT. Robotic-assis-

ted intravesical ureteral reimplantation. In:

Gundeti MS, editor. Pediatric robotic and reconstruc-

tive urology: a comprehensive guide. Hoboken (NJ):

Wiley-Blackwell; 2012. p. 151–9.

22. Yeung CK, Sihoe JD, Borzi PA. Endoscopic cross-

trigonal ureteral reimplantation under carbon dioxide

bladder insufflation: a novel technique. J Endourol

2005;19:295–9.

23. Schomburg JL,HabermanK,Willihnganz-LawsonKH,

et al. Robot-assisted laparoscopic ureteral reimplanta-

tion: a single surgeon comparison to open surgery.

J Pediatr Urol 2014. [Epub ahead of print].

24. Canon SJ, Jayanthi VR, Patel AS. Vesicoscopic

cross-trigonal ureteral reimplantation: a minimally

invasive option for repair of vesicoureteral reflux.

J Urol 2007;178:269–73 [discussion: 73].

25. Valla JS, Steyaert H, Griffin SJ, et al. Transvesico-

scopic Cohen ureteric reimplantation for vesicoure-

teral reflux in children: a single-centre 5-year

experience. J Pediatr Urol 2009;5:466–71.

26. Kasturi S, Sehgal SS, Christman MS, et al. Prospec-

tive long-term analysis of nerve-sparing extravesical

robotic-assisted laparoscopic ureteral reimplanta-

tion. Urology 2012;79:680–3.

Robotic-assisted Ureteral Reimplantation 109

27. Chalmers D, Herbst K, Kim C. Robotic-assisted

laparoscopic extravesical ureteral reimplantation:

an initial experience. J Pediatr Urol 2012;8:

268–71.

28. Akhavan A, Avery D, Lendvay TS. Robot-assisted

extravesical ureteral reimplantation: outcomes and

conclusions from 78 ureters. J Pediatr Urol 2014.

[Epub ahead of print].

29. Emir H, Mammadov E, Elicevik M, et al. Transvesico-

scopiccross-trigonalureteroneocystostomy inchildren:

a single-center experience. J Pediatr Urol 2012;8:83–6.

30. Bayne AP, Shoss JM, Starke NR, et al. Single-center

experience with pediatric laparoscopic extravesical

reimplantation: safe and effective in simple and com-

plex anatomy. J Laparoendosc Adv Surg Tech A

2012;22:102–6.