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Journal of Pediatric Urology (2014) xx, 1.e1e1.e2
VIDEO BANK
Robot-assisted laparoscopic ureteral reimplantation with excisional tailoring for refluxing megaureter Mark A. Faasse, Bruce W. Lindgren, Edward M. Gong* Division of Urology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA Received 23 January 2014; accepted 25 January 2014
KEYWORDS Robotics; Laparoscopy; Megaureter; Vesicoureteral reflux; Ureteral reimplantation
Abstract Objective: To demonstrate a novel technique for robot-assisted laparoscopic excisional tailoring and reimplantation of a refluxing megaureter. Methods: A 9-year-old boy with dysfunctional elimination was found to have a refluxing megaureter and diminished ipsilateral renal function. Robotic ureteral reimplantation with excisional tailoring was performed using a three-port approach. Stay sutures were placed in the anterior aspect of the distal ureter and sequentially lifted to allow freehand excision of redundant ureter. The ureterovesical junction was left intact, and the ureter was repaired over a 6 Fr double-J stent. Detrusorotomy to create flaps for ureteral tunneling was performed with a carbon dioxide (CO2) laser. Results: The patient’s vesicoureteral reflux was successfully corrected, and he is now asymptomatic. Conclusion: Specific technical modifications can facilitate robotic megaureter repair with intracorporeal excisional tailoring. The CO2 laser is advantageous for detrusorotomy. ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction and objective Robot-assisted laparoscopic repair of a megaureter presents unique technical challenges as well as opportunities. In the accompanying video, we demonstrate a robotic approach to excisional tailoring and reimplantation of a
* Corresponding author. E-mail addresses: [email protected], emgong@ northwestern.edu (E.M. Gong).
refluxing megaureter, using a technique that is novel in several respects. Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.jpurol.2014.01.023.
Clinical case A 9-year-old boy who presented with enuresis and constipation was found to have moderate-to-severe right hydroureteronephrosis, high-grade vesicoureteral reflux,
http://dx.doi.org/10.1016/j.jpurol.2014.01.023 1477-5131/ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Faasse MA, et al., Robot-assisted laparoscopic ureteral reimplantation with excisional tailoring for refluxing megaureter, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2014.01.023
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1.e2 and diminished right kidney function. The diameter of the right ureter was 1.6 cm. The patient underwent robotic ureteral reimplantation with excisional tailoring. Postoperative sonography showed decreased hydronephrosis, and voiding cystourethrography confirmed correction of vesicoureteral reflux. The patient is now asymptomatic.
Surgical technique A 6 Fr double-J ureteral stent was inserted cystoscopically, and the patient was then positioned supine in slight Trendelenburg. Three ports were introduced into the abdomen, including a 12-mm laparoscopic port in the umbilicus and an 8-mm robotic instrument port on either side. After mobilization of the distal ureter, several stay sutures were placed in the anterior aspect. These were sequentially lifted from proximal to distal to provide traction for freehand excision of redundant ureter. The ureter was not dismembered from the bladder. Following ureteral repair, a carbon dioxide (CO2) laser was used to incise the detrusor muscle and create flaps for ureteral tunneling. The 12 mm umbilical port is required in order to simultaneously accommodate both the 8.5-mm robotic camera and the flexible laser fiber sheath. Institutional review board approval was obtained for this study.
Discussion Excisional tailoring to reduce the caliber of a megaureter at the time of reimplantation requires certain adaptations when approached laparoscopically or robotically. Previously reported techniques utilized extracorporeal/transportal tailoring [1] or four to five laparoscopic ports to maintain traction on the distal ureter [2,3]. By comparison, we perform intracorporeal tailoring with just three ports. Benefits of fewer laparoscopic ports include better cosmesis, reduced risks associated with trocar introduction, and less port-site complications. Our technique relies on placement of stay sutures to lift the anterior aspect of the ureter for freehand excision, while leaving the ureter attached to the bladder. Subsequent dismembering of the ureter is not always required. When it is, as for reimplantation of an obstructed megaureter, tailoring should be completed before excision of the stenotic segment and reanastomosis of the remaining ureter to the bladder. The detrusorotomy should also be performed prior to this point in the procedure.
M.A. Faasse et al. In the present case, we used a CO2 laser to create the detrusor flaps. At a setting of 6e8 W, the laser allows very precise and hemostatic dissection. Compared with electrocautery, we believe it reduces the risk of bladder mucosal injury. Animal studies have shown that it results in less damage to surrounding tissues [4,5]. This may reduce the risk of postoperative bladder dysfunction and urinary retention, particularly in patients undergoing bilateral ureteral reimplantation.
Conclusion The robotic approach to intracorporeal excisional tailoring and reimplantation of a megaureter can be facilitated by specific technical modifications. The CO2 laser is useful for detrusorotomy, as it causes less collateral tissue damage than electrocautery.
Conflict of interest None.
Funding None.
References [1] Ansari MS, Mandhani A, Khurana N, Kumar A. Laparoscopic ureteral reimplantation with extracorporeal tailoring for megaureter: a simple technical nuance. J Urol 2006;176: 2640e2. [2] 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. [3] Hemal AK, Nayyar R, Rao R. Robotic repair of primary symptomatic obstructive megaureter with intracorporeal or extracorporeal ureteric tapering and ureteroneocystostomy. J Endourol 2009;23:2041e6. [4] Liboon J, Funkhouser W, Terris DJ. A comparison of mucosal incisions made by scalpel, CO2 laser, electrocautery, and constant-voltage electrocautery. Otolaryngol Head Neck Surg 1997;116:379e85. [5] Tulikangas PK, Smith T, Falcone T, Boparai N, Walters MD. Gross and histologic characteristics of laparoscopic injuries with four different energy sources. Fertil Steril 2001;75: 806e10.
Please cite this article in press as: Faasse MA, et al., Robot-assisted laparoscopic ureteral reimplantation with excisional tailoring for refluxing megaureter, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2014.01.023
+
MODEL
Journal of Pediatric Urology (2014) xx, 1.e1e1.e2
VIDEO BANK
Robot-assisted laparoscopic ureteral reimplantation with excisional tailoring for refluxing megaureter Mark A. Faasse, Bruce W. Lindgren, Edward M. Gong* Division of Urology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Box 24, Chicago, IL 60611, USA Received 23 January 2014; accepted 25 January 2014
KEYWORDS Robotics; Laparoscopy; Megaureter; Vesicoureteral reflux; Ureteral reimplantation
Abstract Objective: To demonstrate a novel technique for robot-assisted laparoscopic excisional tailoring and reimplantation of a refluxing megaureter. Methods: A 9-year-old boy with dysfunctional elimination was found to have a refluxing megaureter and diminished ipsilateral renal function. Robotic ureteral reimplantation with excisional tailoring was performed using a three-port approach. Stay sutures were placed in the anterior aspect of the distal ureter and sequentially lifted to allow freehand excision of redundant ureter. The ureterovesical junction was left intact, and the ureter was repaired over a 6 Fr double-J stent. Detrusorotomy to create flaps for ureteral tunneling was performed with a carbon dioxide (CO2) laser. Results: The patient’s vesicoureteral reflux was successfully corrected, and he is now asymptomatic. Conclusion: Specific technical modifications can facilitate robotic megaureter repair with intracorporeal excisional tailoring. The CO2 laser is advantageous for detrusorotomy. ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction and objective Robot-assisted laparoscopic repair of a megaureter presents unique technical challenges as well as opportunities. In the accompanying video, we demonstrate a robotic approach to excisional tailoring and reimplantation of a
* Corresponding author. E-mail addresses: [email protected], emgong@ northwestern.edu (E.M. Gong).
refluxing megaureter, using a technique that is novel in several respects. Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.jpurol.2014.01.023.
Clinical case A 9-year-old boy who presented with enuresis and constipation was found to have moderate-to-severe right hydroureteronephrosis, high-grade vesicoureteral reflux,
http://dx.doi.org/10.1016/j.jpurol.2014.01.023 1477-5131/ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Faasse MA, et al., Robot-assisted laparoscopic ureteral reimplantation with excisional tailoring for refluxing megaureter, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2014.01.023
JPUROL1642_proof ■ 6 March 2014 ■ 2/2
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MODEL
1.e2 and diminished right kidney function. The diameter of the right ureter was 1.6 cm. The patient underwent robotic ureteral reimplantation with excisional tailoring. Postoperative sonography showed decreased hydronephrosis, and voiding cystourethrography confirmed correction of vesicoureteral reflux. The patient is now asymptomatic.
Surgical technique A 6 Fr double-J ureteral stent was inserted cystoscopically, and the patient was then positioned supine in slight Trendelenburg. Three ports were introduced into the abdomen, including a 12-mm laparoscopic port in the umbilicus and an 8-mm robotic instrument port on either side. After mobilization of the distal ureter, several stay sutures were placed in the anterior aspect. These were sequentially lifted from proximal to distal to provide traction for freehand excision of redundant ureter. The ureter was not dismembered from the bladder. Following ureteral repair, a carbon dioxide (CO2) laser was used to incise the detrusor muscle and create flaps for ureteral tunneling. The 12 mm umbilical port is required in order to simultaneously accommodate both the 8.5-mm robotic camera and the flexible laser fiber sheath. Institutional review board approval was obtained for this study.
Discussion Excisional tailoring to reduce the caliber of a megaureter at the time of reimplantation requires certain adaptations when approached laparoscopically or robotically. Previously reported techniques utilized extracorporeal/transportal tailoring [1] or four to five laparoscopic ports to maintain traction on the distal ureter [2,3]. By comparison, we perform intracorporeal tailoring with just three ports. Benefits of fewer laparoscopic ports include better cosmesis, reduced risks associated with trocar introduction, and less port-site complications. Our technique relies on placement of stay sutures to lift the anterior aspect of the ureter for freehand excision, while leaving the ureter attached to the bladder. Subsequent dismembering of the ureter is not always required. When it is, as for reimplantation of an obstructed megaureter, tailoring should be completed before excision of the stenotic segment and reanastomosis of the remaining ureter to the bladder. The detrusorotomy should also be performed prior to this point in the procedure.
M.A. Faasse et al. In the present case, we used a CO2 laser to create the detrusor flaps. At a setting of 6e8 W, the laser allows very precise and hemostatic dissection. Compared with electrocautery, we believe it reduces the risk of bladder mucosal injury. Animal studies have shown that it results in less damage to surrounding tissues [4,5]. This may reduce the risk of postoperative bladder dysfunction and urinary retention, particularly in patients undergoing bilateral ureteral reimplantation.
Conclusion The robotic approach to intracorporeal excisional tailoring and reimplantation of a megaureter can be facilitated by specific technical modifications. The CO2 laser is useful for detrusorotomy, as it causes less collateral tissue damage than electrocautery.
Conflict of interest None.
Funding None.
References [1] Ansari MS, Mandhani A, Khurana N, Kumar A. Laparoscopic ureteral reimplantation with extracorporeal tailoring for megaureter: a simple technical nuance. J Urol 2006;176: 2640e2. [2] 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. [3] Hemal AK, Nayyar R, Rao R. Robotic repair of primary symptomatic obstructive megaureter with intracorporeal or extracorporeal ureteric tapering and ureteroneocystostomy. J Endourol 2009;23:2041e6. [4] Liboon J, Funkhouser W, Terris DJ. A comparison of mucosal incisions made by scalpel, CO2 laser, electrocautery, and constant-voltage electrocautery. Otolaryngol Head Neck Surg 1997;116:379e85. [5] Tulikangas PK, Smith T, Falcone T, Boparai N, Walters MD. Gross and histologic characteristics of laparoscopic injuries with four different energy sources. Fertil Steril 2001;75: 806e10.
Please cite this article in press as: Faasse MA, et al., Robot-assisted laparoscopic ureteral reimplantation with excisional tailoring for refluxing megaureter, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2014.01.023
