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Robot-assisted laparoscopic ureteric reimplantation: extravesical technique Pankaj P. Dangle, Anup Shah* and Mohan S. Gundeti†‡ Department of Surgery, Division of Urology, University of Chicago Medicine and Biological Sciences, *Pritzker School of Medicine, University of Chicago Medicine and Biological Sciences, †Center for Pediatric Robotic and Minimal Invasive Surgery, Department of Surgery, Division of Urology, University of Chicago Medicine and Biological Sciences, and ‡ Comer Children's Hospital, Chicago, IL, USA

Objectives To describe our standardised approach to performing robot-assisted extravesical ureteric reimplantation.

resolution of VUR in 32/40 ureters (80%). Of the remaining refluxing ureters, downgrading of VUR on VCUG was shown in 7/8 ureters (87.5%). The mean (range) length of hospital stay was 1.8 (1–3) days.

Patients and Methods A total of 29 children, with high grade (III–V) vesico-ureteric reflux (VUR) underwent robot-assisted extravesical ureteric reimplantation between September 2010 and September 2013. Follow-up renal ultrasonography was performed at 1 month and 3 months and a voiding cysto-urethrogram (VCUG) was obtained at 4 months to assess VUR resolution.

Results The mean (range) patient age at the time of surgery was 5.38 (3.0–10.0) years. Postoperative VCUG showed complete

Introduction Several surgical approaches to ureteric reimplantation have been described. Traditionally, an open approach has been considered the ‘gold standard’, while laparoscopic techniques, although minimally invasive, were unpopular. The robot-assisted technique, featuring 6° of freedom articulation, has the potential to overcome the technical challenges presented by conventional laparoscopy. This technique is adopted from open and laparoscopic surgery, but so far its robotic application has not been described [1,2]. In the present paper, we describe our standardised approach to performing robot-assisted extravesical ureteric reimplantation. We highlight the fact that evaluation of our own technique and the corresponding clinical results have led us to modify our technique to improve reflux resolution rates. The technique described in the present study is our current modified technique.

Patient Selection All patients included in the study were children with high grade (III–V) VUR, documented on voiding cysto-

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Conclusions In conclusion, robot-assisted extravesical ureteric reimplantation is technically feasible with acceptable resolution of VUR.

Keywords robotic, reimplantation, ureter, extravesical

urethrogram (VCUG), and were toilet-trained before the repair. Patients with bilateral reflux and duplex ureters were included in this group. Patients with a solitary kidney, previous failed repair or associated intravesical congenital anomalies were offered an open surgical approach.

Patient Positioning After general anaesthesia, the patient is placed in a low lithotomy position, all pressure points are well padded, the patient is secured to the table with the help of silk tape over padded foam, and the operating table is placed in the Trendelenburg position. An age-appropriate Foley catheter is inserted using sterile precautions, to be used later for bladder hydrodistension intra-operatively during the detrusorotomy and for postoperative urine drainage.

Peritoneal Access We use an open Hasson’s technique to gain access to the peritoneal cavity. A 12-mm balloon camera port is then placed at the level of the umbilicus via an infra-umbilical incision. © 2014 The Authors BJU International © 2014 BJU International | doi:10.1111/bju.12813 Published by John Wiley & Sons Ltd. www.bjui.org

Robot-assisted extravesical reimplantation

In younger children this is placed supra-umbilically, if the pubo-umbilical distance is shorter than 10 cm.

Port Placement Once the access to the peritoneal cavity is obtained, we develop a pneumoperitoneum with an insufflation pressure of 10–12 mmHg and flow of 2–5 L/min, depending on patient age. We then place our two 8-mm robotic ports and a 5-mm assistant port. The robotic working ports are placed ∼6–8 cm from the camera port in the same line. We use an empty trocar to indent the skin; a precise skin incision (along the diameter of circle) is made for snug fitting of the trocar. Once both the 8-mm ports are placed, the 5-mm assistant port is placed on the left side, equidistant (4–6 cm) from the camera and robotic port. Because of the small working space, we pass our robotic instruments under vision before docking the camera, as this avoids accidental injury to the intra-abdominal organs.

Identification of Ureter Once the robot is docked and precise bipolar forceps and monopolar scissors are located inside the abdominal cavity, attention is turned to the pelvic portion of the ureter. The ureter is identified by its vermicular movement and the anatomical landmarks. The peritoneum covering the ureter is incised and the ureter is mobilised to the level of the vas deferens or uterine artery. An umbilical tape is then looped around the ureter, which allows manipulation of the ureter without direct handling during the entire procedure.

the error of detrusorotomy tunnel length measurement. A transabdominal hitch stitch (2/0 polyglactin 910) is placed to elevate the bladder to aid in the detrusorotomy. The stitch is placed in midline for bilateral cases and is placed laterally for unilateral reimplantation.

Detrusorotomy We then direct our attention to detrusorotomy and take the utmost precaution to make the detrusorotomy in the direction of the vesico-ureteric junction to prevent future angulation. A 5-cm detrusorotomy is created with the use of monopolar scissors without entering the bladder mucosa. If there is an inadvertent entry into the bladder mucosa, the mucosa is approximated with running 5/0 or 6/0 poliglecaprone 25 sutures. A permanent stay stitch (5/0 polydiaxonone) is then placed at the apex of the detrusorotomy through the ureteric adventitia to align the ureter within the tunnel and to prevent slippage after the surgery is completed. The detrusorraphy is performed using a running stitch (5/0 polydiaxonone) that starts at the distal aspect of the detrusorotomy and incorporates the ureteric adventitia in the closure. The inclusion of the adventitia starts at the vesico-ureteric junction and is repeated at at least one or two more sites as the closure continues. We do not place separate advancement sutures as described in the open technique [5]. After detrusorraphy at the apex, precaution is taken not to make the closure tight and, ideally, there should be space to accommodate the tip of the needle holder.

Creation of Peritoneal Window A peritoneal window is then created distal to the vas deferens or uterine artery and the ureter is then freed underneath, preserving these structures. The dissection is performed whilst staying in close proximity to the ureter, especially at the vesico-ureteric junction and distal ureter, to preserve the ureteric adventitia and vascularity. Based on an anatomical cadaveric mapping study, Leissner et al. [3] reported the critical location of the neurovascular bundle to be dorsomedial at the distal 2.5 cm of the ureter and dorsocranial to the trigone. The authors also hypothesised that damage to these structures may be the aetiology for postoperative bladder dysfunction [4]. To avoid inadvertent injury to the bundle, we limit the dissection over the distal 2.5 cm of the ureter, with extreme caution in bilateral cases. Often it is difficult to locate the ureter distal to the vas or uterine artery so we try to locate the ureter above these structures.

Bladder Distension Sterile saline is used to fill the bladder for facilitating detrusorotomy. The volume used is 60 mL in all patients to maintain a consistency of bladder distension and reduce

Closure At the end of the procedure, the fascia is closed at each incision, including the 5-mm assistant port. We adopted this practice after encountering an omental hernia after carrying out transperitoneal laparoscopic procedures.

Postoperative Care Pain control is usually obtained with oral analgesic medication or often narcotics are used as required. Diet is advanced on the same day as tolerated. In unilateral cases the catheter is removed on postoperative day 1 and on day 2 in bilateral cases. A post-void bladder scan is obtained to confirm bladder emptying before discharge from hospital.

Follow-Up Follow-up renal ultrasonography is performed at 1 month and 3 months and VCUG is obtained at 4 months to assess the VUR resolution. In some cases, we have observed transient asymptomatic self-resolving hydronephrosis on postoperative ultrasonography. © 2014 The Authors BJU International © 2014 BJU International

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Outcomes A total of 29 patients (18 unilateral, 11 bilateral cases, for a total of 40 ureters) underwent robot-assisted laraparoscopic ureteric reimplantation, performed using the described extravesical technique, between September 2010 and September 2013. This technique has been modified based on video analysis of individual cases and the ongoing evolution of our experience over a period of time. Preoperatively, grade III–V VUR was observed in a total of 37 ureters, while grade I–II VUR was observed in three ureters (these were contralateral reflux of high grades). The mean (range) patient age at the time of surgery was 5.38 (3.0–10.0) years. Postoperative VCUG showed complete resolution of VUR in 32/40 ureters (80%). Of the remaining refluxing ureters, downgrading of VUR on VCUG was shown in 7/8 ureters (87.5%). The mean (range) length of hospital stay was 1.8 (1–3) days.

Conflict of Interest M.S.G. reports other funding from Intuitive Surgical during the conduct of the study. The remaining authors have no conflict to declare.

References 1

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Lendvay T. Robotic-assisted laparoscopic management of vesicoureteral reflux. Adv Urol 2008; 2008: 732942

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Smith RP, Oliver JL, Peters CA. Pediatric robotic extravesical ureteral reimplantation: comparison with open surgery. J Urol 2011; 185: 1876–81 Leissner J, Allhoff EP, Wolff W et al. The pelvic plexus and antireflux surgery: topographical findings and clinical consequences. J Urol 2001; 165: 1652–5 Dangle PP, Razmaria AA, Towle VL, Frim DM, Gundeti MS. Is pelvic plexus nerve documentation feasible during robotic assisted laparoscopic ureteral reimplantation with extravescial approach? J Pediatr Urol 2013; 9: 442–7 Zaontz MR, Maizels M, Sugar EC et al. Detrusorrhaphy: extravescial ureteral advancement to correct vesicoureteral reflux in children. J Urol 1987; 138: 947–9

Correspondence: Pankaj P. Dangle, Department of Surgery, Division of Urology, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Avenue, MC 7122, Chicago, IL 60637 USA. e-mail: [email protected] Abbreviation: VCUG, voiding cysto-urethrogram.

Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Video S1 Critical step-by-step approach for robot-assisted extravesical reimplantation.

Robot-assisted laparoscopic ureteric reimplantation: extravesical technique.

To describe our standardised approach to performing robot-assisted extravesical ureteric reimplantation...
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