Single-Center Experience with Pediatric Laparoscopic Extravesical Reimplantation: Safe and Effective in Simple and Complex Anatomy

Abstract

Purpose:

Minimally invasive approaches to the surgical management of vesicoureteric reflux (VUR) have become more prominent over the last 10 years with progress in both endoscopic and laparoscopic/robotic surgery. We hypothesized that laparoscopic extravesical detrussoraphy (LED) for the management of VUR in children with complex bladders and/or bilateral VUR was safe and effective.

Subjects and Methods:

Under institutional review board approval we evaluated the charts of all patients seen at our institution over the last 8 years who had undergone LED for the management of VUR. We evaluated demographic variables, surgical variables, and postoperative results. Postoperative bladder function was examined in the patients as well as need for secondary procedures. Patients with complex bladders included all patients who had previous surgery on the affected side, neurogenic bladders, and duplex or complex anatomy.

Results:

Ninety-eight patients with 144 ureters were treated during this time period. The overall VUR resolution by voiding cystourethrogram was 95.2%. The average age was 6.74 years, with 13 children over the age of 12 years old. Average length of stay (LOS) was 1.7 days for children 5 years and older and 1.0 days for children less than 5 years old (P=.004). LOS was not affected by body mass index or complexity of the procedure. There were 46 bilateral procedures, and the incidence of urinary retention was 6.5% versus 0% in the unilateral group (P=.09). Of our patients, 27.6% had complex bladders, including 9 patients with complete ureteral duplications, 10 with periureteral diverticula, and 8 with prior surgery on the affected side. There were two complications requiring a second procedure in this group (7%). No patient with a complex bladder had persistent VUR.

Conclusion:

LED for the management of children with complex bladders and VUR is safe and effective. This technique is versatile and achieves high VUR resolution rates with minimal morbidity.

Introduction

Parents of children with vesicoureteric reflux (VUR) must choose between a variety of treatment options with different risks and benefits. The ideal treatment is different for every child and family. Endoscopic treatment of reflux has gained considerable popularity as it offers the benefits of a minimally morbid procedure with an opportunity to cure.¹ Open surgery for VUR is more successful than endoscopic but is unarguably more invasive.² For children with complex ureteral and periureteral anatomy, however, endoscopic therapy has been shown to be less successful than in simple anatomic systems.^3–5 Lower success rates in the endoscopic group have led parents and surgeons to look for less morbid options to open surgery that retain the same high success rate. Laparoscopic management of reflux offers the advantage of a minimally invasive procedure with the ability to manage complex anatomy and achieve higher success rates than endoscopic therapy.

In the open and laparoscopic management of VUR an intravesical or extravesical technique can be used. Both have similar success rates, but the risk of urinary retention in children with bilateral VUR has made many surgeons choose an intravesical approach in these children. The drawbacks to the intravesical approach are greater pain, hematuria, and bladder instability. Contemporary surgical series of both laparoscopic and open techniques have shown low rates of urinary retention after bilateral extravesical ureteral reimplantation and short hospital stays.^6–8 We hypothesize that laparoscopic extravesical ureteroneocystotomy can achieve high success rates with minimal morbidity in patients with simple or complex ureteral anatomy. We evaluated a single pediatric tertiary center experience with the laparoscopic extravesical reimplantation in patients with simple and complex ureteral and bladder anatomy.

Subjects and Methods

Under an institutional review board–approved protocol we retrospectively evaluated the charts of all children undergoing laparoscopic extravesical detrusorraphy (LED) at our institution from August 2001 to July 2009. Demographic parameters included age, gender, weight, height, body mas index, and presence of preoperative dysfunctional elimination syndrome (DES). DES is defined as constipation requiring treatment, severe urge, urinary retention requiring treatment, and/or daytime incontinence. Preoperative parameters evaluated were the grade of VUR, the side of VUR, and the presence of complex anatomy, which included complete ureteral duplication, presence of ureteral diverticulum, and/or prior surgery on the affected ureteral unit. For children who were surgical candidates the patient's families made the choice of a laparoscopic procedure after the options of open, laparoscopic, and endoscopic surgery were discussed. In this single surgeon series there were several patients who had endoscopic and open surgery, and they are not included in this surgical series. There were no specific exclusion criteria for laparoscopic surgery, but very young children and those with severe ureteral dilation generally were generally counseled to undergo open reconstruction. Postoperative parameters evaluated included length of hospital stay (LOS), febrile and culture-positive urinary tract infections (UTIs), de novo DES, postoperative VUR grade, postoperative ultrasound (US) appearance, length of follow-up, presence and type of complications, and need for additional procedures.

Surgical technique

The surgical technique used consisted of standard Veres laparoscopic access to the abdomen generally through the umbilicus. Three 5-mm working ports were used. In girls the space between the uterus and bladder was developed. In boys, the peritoneum on the posterior side of the bladder was incised and reflected inferiorly and laterally until the ureter was encountered with care to avoid the vas deferens. Ureteral dissection was performed with an emphasis on medial dissection avoiding lateral injury to the nerve plexus of the bladder.⁸ Holding stitches placed through the abdominal wall were used to elevate the bladder. A detrusor tunnel was created using electrocautery to expose the bladder submucosa. The tunnel was made using a needle-point monopolar cautery to incise the detrusor muscle through its full thickness to expose the bladder submucosa. The tunnel was created to roughly 4–5 times the width of the ureter or ureteral complex. The ureter was placed in the tunnel, and the bladder muscle was closed over the ureter in the tunnel using a series of interrupted monofilament absorbable 4-0 sutures. For particularly large ureters or duplex systems a slightly longer and wider detrusor tunnel was created. Bladder catheterization was performed with the patient under anesthesia and remained overnight. The catheter was typically removed in the morning after surgery, and the child was required to void prior to discharge.

Postoperative follow-up

Postoperative follow-up consisted of a renal and bladder US at 1 month with a second US at 3 months if the first was not normal. Voiding cystourethrogram (VCUG) was performed early in the learning curve until VUR resolution rates were confirmed to be similar to the open procedure. In the later experience VCUG was performed only after a febrile UTI or for persistent abnormal US findings. When performed, the VCUG was done between 6 and 10 weeks postoperatively.

Statistical analysis

Descriptive statistics were calculated for patient cohorts. Categorical data was analyzed using the chi-square distribution. Continuous data were analyzed using paired independent sample t test. Non-parametric data were evaluated using the Mann–Whitney analysis. P values were considered significant at or below a value of .05.

Results

Patients and procedures

In total, 144 ureters in 98 patients were treated with an LED over the 8-year study period (Table 1). Mean patient age was 6.7 years (range, 0.9–20.3 years), with 83 of the 98 (84.7%) female. Thirteen patients were over 12 years of age. Mean patient body mass index was 18.0 kg/m² (range, 13.6–33.4 kg/m²), and mean patient weight was 27.3 kg, with 22 children weighing less than 15 kg. Preoperative DES was identified in 24 (24.5%) patients.

Table 1.

Characteristics of Patients

Variable	Number (% or range)
Number of patients	98
Age (years)
Median	6
Mean	6.7
Right-sided	30 (30.6%)
Bilateral	46 (46.9%)
Ureters treated	144
Female	83 (84.7%)
BMI (kg/m²)	18 (13.6–33.4)
Mean preoperative VUR grade	3.2 (1–5)
DES	24 (27%)
Complex anatomy
Ureteral diverticulum	10
Prior surgery	10
Complete ureteral duplication	9

BMI, body mass index; DES, dysfunctional elimination syndrome; VUR, vesicoureteric reflux.

Mean preoperative reflux grade was 3.2 (range, 1–5), and VUR occurred on the right in 22 (22.4%) patients and bilaterally in 46 (46.9%) patients. Twenty-nine patients had non-simple urologic anatomy. Table 1 shows the number and type of complex anatomy encountered intraoperatively.

Efficacy and safety

Reflux resolved in 29 of 31 patients (93.5%) and 40 of 42 ureters (95.2%) on postoperative VCUG (Table 2). Average LOS was 1.7 days for children 5 years and older and 1.0 days for children less than 5 years old (P<.01). LOS was not affected by body mass index or complexity of the procedure. Postoperatively, new hydronephrosis occurred in 28 of 93 patients (30.1%). Of those patients with new hydronephrosis 24 of 26 (92.3%) had returned to their baseline at their second US. A total of 3 patients required a second procedure in the postoperative setting, including two temporary ureteral stents for acute ureteral obstruction, both of which had complicated ureteral anatomy; the other patient required a temporary ureteral stent and pelvic drain for persistent urine leak after intraoperative ureterotomy. Another patient with a solitary kidney had a transient rise in serum creatinine and new-onset hydronephrosis that resolved without stenting over a 1-week period of time that was classified as having acute obstruction. Two patients had intraoperative complications with both being an inadvertent ureterotomy during the detrusor tunnel dissection. One of the patients is described above, and this was not detected intraoperatively; the other child developed an ureterovesical fistula requiring a repeat laparoscopic detrusorraphy of her affected side to eliminate her reflux. This ureterotomy was detected intraoperatively, and an attempt at primary repair was performed. This patient had presented with impaired renal function secondary to a neurogenic bladder from spinal cord tethering and following puberty required renal transplantation.

Table 2.

Clinical Outcomes

Variable	Simple	Complex	P value
Estimated blood loss (mL)	17.2	11.4	.17
LOS (days)	1.3	1.4	.67
Mean postoperative follow-up (months)	8.2	8.0	.92
VUR resolution	22/23 (95.7%)	7/8 (87.5%)	.46
Hydronephrosis worse at
1 month	21/66 (31.8%)	7/27 (25.9%)	.57
3 months	2/20 (10.0%)	0/6	1.00
Contralateral VUR	0/18	0/11	1.00

LOS, length of stay.

Retention and UTI

Of our patients, 16.7% (15/90) had postoperative culture-proven UTI, with only 11 having febrile UTI. Nine of these patients with febrile UTI had a postinfection VCUG, and only 1 patient (11.1%) had persistent VUR (Grade 2 postoperatively with preoperative Grade 4) (Table 3). The other two patients did not complete the VCUG and were lost to follow-up. Urinary retention occurred in 6.5% (3/46) of children with bilateral reimplantations and in no child (0/52) undergoing unilateral reimplantation (P=.09). One of the children with retention presented postoperatively with a febrile UTI. This child had severe developmental delay, was nonverbal, and was not toilet-trained at 5 years old when surgery was performed. There was no true postvoid residual obtained, but because of the UTI and a persistent volume of half of the expected capacity shortly after voiding, it was felt that the child had some element of retention by the clinician. No catheter was placed in this child, but the mother of the child would place the child on the toilet every 2 hours to encourage timed voiding. The other two children had symptomatic retention requiring catheterization, but neither child required catheterization for longer than 1 month.

Table 3.

Complications by Procedure Type

Variable	Simple	Complex	P value
Urinary retention	3/61 (4.9%)	0/27 (0%)	.55
Unilateral	0/33 (0%)	0/19 (0%)	1.00
Bilateral	3/38 (7.9%)	0/8 (0%)	1.00
UTI	11/63 (17.5%)	4/27 (14.8%)	1.00
Ureteral obstruction	1/61 (1.6%)	2/27 (7.4%)	.22

UTI, urinary tract infection.

Discussion

The management of VUR is continuously evolving with a recent surge in the number of procedures that are considered minimally invasive.¹ Endoscopic procedures offer less morbidity from standard open ureteroneocystotomy, but they have the down side of having less success in high-grade and complex anatomy.^2–5 Laparoscopy offers many of the benefits of a minimally invasive approach while maintaining the success of a gold standard open operation.^9,10 One of the many benefits of laparoscopy, however, is the ability to perform multiple operations through a single set of small incisions as well as to completely inspect the abdomen at the same time.¹¹ Another benefit in using a laparoscopic approach is the ability to see the natural lie of the ureter in the detrusor tunnel and in the abdomen after completion of the detrusorraphy. This aids in reducing complications from ureteral kinking or other extravesical pathology.

The extravesical approach itself is considered by some to be minimally invasive.^6,12 Many children are able to achieve same-day surgery with minimal voiding difficulty. Most previous studies of children undergoing extravesical reimplantation have been performed using inguinal or lower abdominal incisions.^6,12 These studies have VUR resolution rates that are similar to intravesical approaches but spare the children the bladder instability and hematuria associated with the intravesical approach. One limitation of this technique is that the ureter cannot be visualized in its natural lie in the abdomen, and the remainder of the ureter cannot be visualized for any other potential pathology.

The technique of both the laparoscopic and extravesical approach has the unique ability to offer patients the benefit of two minimally invasive techniques. In this series we show that a high success rate with minimal morbidity can be achieved. This series represents the largest group of patients undergoing laparoscopic and extravesical ureteral reimplantation in the literature and describes the wide applicability of this technique. Others have reported previously on the benefits of the combined laparoscopic and extravesical approach but in much smaller series.^7,8,13–16

For patients with VUR into anatomically complex ureteral and bladder units most of the literature has focused on endoscopic and open management with only a few case reports of patients being managed using laparoscopic techniques.^{4,5,14,16–20} These series have shown that endoscopic techniques offer the benefit of minimally invasive surgery but have far lower success rates. Patients who have complex anatomy or have failed prior surgery were previously left with only open surgery to treat their VUR. We show VUR resolution in all but one of these patients who were evaluated with VCUG, which is comparable to other open series for patients with complex anatomy.^18,21–23 We feel that the laparoscopic approach offers a greater chance of reflux resolution over endoscopic surgery although at greater risk of postoperative complications. The laparoscopic approach does offer a true reconstructive option for patients, and this makes it well suited to manage children with complex ureteral anatomy.

In our study we had 3 patients who had transient urinary retention after bilateral extravesical detrusorraphy. There were no children with voiding difficult in the unilateral group. These findings agree with others who have performed bilateral extravesical reimplantation.²⁴ A recent series of robotic extravesical ureteral reimplantations using the same technique showed a nearly 30% rate of postoperative urinary retention in children undergoing bilateral procedures.²⁵ Although our rate is much lower, there is certainly a real risk of this happening in patients using the extravesical approach in bilateral VUR, and it should be recognized that this might bias some surgeons toward an intravesical approach for children with bilateral VUR. We agree that lateral dissection should be limited to avoid damage to pelvic nerves.^7,8 We also agree that both parents and patients should be educated preoperatively and postoperatively about good bladder habits, and children should be encouraged to void on a regular schedule in the first few days postoperatively.⁶

The laparoscopic approach has many technical considerations that must be mastered in order to perform the extravesical detrusorraphy. The most technically challenging part of the procedure is the intracorporeal suturing. This must be performed in a small working space in the pelvis and is at a more difficult angle than the suturing during laparoscopic pyeloplasty. These results should be applicable to the robotic approach that offers ease of suturing for the surgeon who has difficulty with laparoscopic suturing. The second challenge is performing a familiar dissection through an unfamiliar view. Most pediatric urologists feel comfortable with the ureteral dissection through the extravesical or transvesical approach, but this view is very different when the dissection is visualized from a laparoscopic approach with the surgeon working from the head of the patient. Developing the space between the uterus and vagina in girls can be challenging early in the learning curve. This becomes more difficult in the postpubertal female when the vaginal and uterine vascularization increases notably. The final challenge during the surgery is the creation of the detrusor tunnel. This can be difficult, and perforation of the mucosa can occur. Ureteral perforation in the intravesical approach is very rare, and this could represent a drawback to the laparoscopic approach. Although the rate of perforation in our series was low, this is certainly an area for concern and technique improvement. Care in avoiding the ureter must also be used to prevent injury to this structure. Despite these limitations the laparoscopic approach offers wide applicability and low morbidity for children with simple and non-simple anatomy.

Our study has several limitations. The study design is retrospective, and the follow-up is limited in several patients. VCUGs were performed in all patients during initial cases, but after reflux resolution was seen in all but one patient of the first 20 patients, the surgeon shifted to performing VCUG on patients with recurrent UTI or persistent hydronephrosis. Thus, we have VCUG data on only about one-third of the patients. Another limitation is the lack of a formal voiding analysis in the postoperative setting. Not all patients had postvoid residuals, and there was no voiding diary kept in most patients. All patient and parents are questioned about their child's urinary habits postoperatively, but this was not objectively assessed and recorded. Despite these limitations we feel that LED offers many of the benefits and versatility of open surgery in a minimally invasive approach. Although reflux resolution rates are slightly lower and there were several complications not seen in the intravesical approach, we feel this approach shows real promise and can be used safely and successfully in both simple and complex ureteral anatomy. While not a gold standard to replace the open approach, we feel this technique has great merit and warrants further prospective studies in larger patient series.

Conclusion

LED is a safe and effective procedure for the management of VUR in both simple and complex ureteral anatomy. Mucosal perforation can occur during ureteral dissection, and transient urinary retention may occur in children undergoing bilateral LED. LED offers patients VUR resolution rates higher than those of endoscopic therapy and approaching those of open surgery while still being a minimally invasive reconstructive procedure.

Footnotes

Disclosure Statement

No competing financial interests exist.

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