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International Journal of Urology (2015)
doi: 10.1111/iju.12702
Original Article
Transvesicoscopic ureteral reimplantation: Politano–Leadbetter versus Cohen technique Shigehiro Soh,1 Yoshitomo Kobori,1 Takeshi Shin,1 Keisuke Suzuki,1 Toshiyuki Iwahata,1 Yuko Sadaoka,1 Ryo Sato,1 Morihiro Nishi,2 Masatsugu Iwamura2 and Hiroshi Okada1 1
Department of Urology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, and 2Kitasato University School of Medicine, Sagamihara, Japan Abbreviations & Acronyms Bil = bilateral DMSA = dimercaptosuccinic acid OAB = overactive bladder VCUG = voiding cystourethragrapy VUJO = vesicoureteral obstruction VUR = vesicoureteral reflux Correspondence: Shigehiro Soh M.D., Ph.D., Department of Urology, Dokkyo Medical University Koshigaya Hospital, 2-1-50 Minami-Koshigaya, Koshigaya 343-8555, Japan. Email: [email protected] Received 27 August 2014; accepted 3 December 2014.
Objectives: To compare the outcomes of the Politano–Leadbetter and Cohen techniques in laparoscopic pneumovesicum approach for ureteral reimplantation. Methods: We retrospectively reviewed the medical records of 24 patients who underwent transvesicoscopic ureteral reimplantation during the period from 2007 to 2014. The patients were treated with either the Cohen or Politano–Leadbetter technique. Operative duration, duration of hospital stay, and success and complication rates were compared. Results: Operative duration was 1 h longer for the Politano–Leadbetter technique than for the Cohen technique (P < 0.05). Foley catheters were removed 2–3 days after the procedures. The mean hospital stay was 3.6 days. Reflux completely resolved in 21 patients (35 ureters, 94.6%), but not in two patients (2 ureters). There was no difference in the success rate or durations of catheterization or hospital stay between patients treated with the Politano–Leadbetter technique and those treated with the Cohen technique. Conclusions: The Politano–Leadbetter and Cohen techniques are both reliable for transvesicoscopic ureteral reimplantation. Despite a longer operative time, because of the higher surgical complexity, the Politano–Leadbetter ureteral reimplantation offers important physiological advantages over other techniques.
Key words:
laparoscopic, pneumovesicum, transvesical, ureteral reimplantation, vesicoureteral
reflux.
Introduction Laparoscopic surgical techniques have replaced open surgical management for a number of pediatric urological conditions. Minimally invasive surgical procedures using these techniques have been shown to be effective in managing VUR in children. Lakshmanan et al. were the first to describe laparoscopic extravesical reimplantation in humans.1 Since then, a number of endoscopic and laparoscopic ureteral reimplantation techniques have been developed to treat VUR and vesicoureteral junction obstruction.1–14 A novel minimally invasive cross-trigonal ureteral reimplantation technique under pneumovesicum, reported by Yeung, is now widespread and has better success rates than open cross-trigonal reimplantation.2 The transvesicoscopic Cohen technique for cross-trigonal ureteral reimplantation has been frequently described; however, there have been no reports regarding the Politano–Leadbetter technique.2–7 The theoretical advantages of ureteral reimplantation using the Politano–Leadbetter technique include the ability to create a long tunnel and carry out retrograde catheterization through the normal ureteral orifice.15 However, the difficulty of creating a new cephalad hiatus has slowed uptake of this procedure among surgeons. We used two intravesical techniques during this study period, and developed a new method that uses a laparoscopic pneumovesicum approach for the Politano–Leadbetter and Cohen techniques. We describe the details of this new method and retrospectively review our outcomes with these two techniques.
Methods Patients We retrospectively reviewed the medical records of patients who underwent ureteral reimplantation surgery during the period from 2007 to 2014. The study was carried out as a © 2015 The Japanese Urological Association
1
S SOH ET AL.
clinical trial (no. 1424) under the supervision of physicians at Dokkyo Medical University Koshigaya Hospital, Koshigaya, Japan, after approval from the institutional review board had been obtained. On the basis of our experience, female patients older than 4 years with a bladder capacity greater than 200 mL (as determined by vesicourethral cystography) were considered suitable candidates for the pneumovesicum technique. All patients (or parents, in the case of pediatric patients) were asked if they preferred laparoscopic surgery; however, the present study includes only those who chose transvesicoscopic ureteral reimplantation. A total of 23 female patients with persistent primary grade II–IV VUR (Table 1) were offered various management options, and selected and gave informed consent for pneumovesicum ureteral reimplantation. All surgeries were carried out by the same surgeon (SS). Among the 24 patients, 12 were treated with the Politano–Leadbetter technique and 12 were treated with the Cohen technique. One girl with vesicoureteral junction obstruction and symptomatic ureteral calculi also selected this procedure. She underwent transvesicoscopic ureteral reimplantation by the Politano– Leadbetter technique without ureteral tailoring, because the dilatation of the ureter was mild. The technique was randomly selected, except for one girl who had vesicoureteral junction obstruction. The median patient age was 10 years (range 4–38 years). However, the procedure was not selected by the patient’s age, and there was a difference in median age between the Politano–Leadbetter and Cohen technique (Tables 2, 3). Six of the 23 patients with VUR (26%) had urgent incontinence, and nine (39%) had constipation. Any patients with associated symptoms of overactive bladder received Table 1 Patients’ characteristics Case no.
Age (years)
Urgent†
Constipation
Febrile UTI‡
Renal scarring
VUR grade (left/right)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
10 6 9 5 4 10 23 29 9 25 17 11 7 6 15 4 38 7 8 38 17 10 9 19
None None None Yes None None None Yes None Yes None None Yes None None None Yes None None Yes Yes None None None
None None None Yes None None None Yes None Yes None None Yes None Yes None Yes None None Yes None Yes None Yes
Yes Yes None Yes Yes None Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes None Yes None None Yes Yes Yes Yes None Yes None Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
4/– –/3 VUJO/– 3/2 2/4 2/3 3/– 3/– 4/4 –/3 3/3 3/3 4/2 1/3 2/– –/4 3/2 2/– 1/3 3/2 3/– 3/4 3/3 3/1
†Urgent sense or incontinence. ‡Constipation, febrile urinary tract infection.
2
appropriate management, including a voiding diary, timed voiding and anticholinergic agents, before surgery was considered. In addition, patients with bowel dysfunction were treated with stool softeners and laxatives. Of the 23 patients with VUR, 22 had a breakthrough urinary tract infection and/or multiple pyelonephritic renal scars on DMSA renal scanning. Two patients who developed a recurrence after endoscopic treatment with Deflux or collagen were included in the study: one underwent transvesicoscopic Cohen reimplantation and the other was treated using the Politano–Leadbetter technique.
Surgical techniques The pneumovesicum Politano–Leadbetter technique was carried out using an original method. As in previous reports, the bladder was distended with saline during cystoscopic examination and was fixed percutaneously to the abdominal wall with 20 absorbable sutures.2 A midline was established between the umbilicus and the top of the pubic bone. An 8-mm incision was then made in the abdominal wall, 1 cm below the midline. Then, an 18-G needle was passed through the incision into the bladder, and a 3-0 absorbable suture was threaded through the needle and left in place. Another 18-G needle was then passed through an adjacent puncture in the bladder, through which a looped suture was inserted into the bladder. Using the biopsy forceps of the cystoscope, the suture was retrieved, pulled through the loop of the suture and extracted. The suture was then tied and pulled up, to stretch the bladder wall, while a 5mm step port for the camera was inserted into the bladder. After percutaneous fixation of the first port, the second and third ports were made in the abdominal wall in the same manner, 2.5– 3.0 cm lateral to the first port, on both sides. We used a 3-mm port for left-hand maneuvers and a 5-mm port for right-hand maneuvers. After the port placements, we drained the saline solution and inflated the bladder with gas. The insufflation pressure of CO2 was 8 mm Hg. A 4-cm–long ureteral stent tube was prepared from a 4-Fr infant feeding tube. The stent tube was inserted into a ureteral orifice and fixed with a 5-0 absorbable suture placed below the ureteral orifice. Lifting the suture line allows circumferential cutting of the bladder epithelium and the Waldeyer sheath around the orifice, using miniature endoscissors and a monopolar hook (Fig. 1). To free the ureter from the bladder wall, a plane was then developed between the bladder muscle and ureteral adventitia. Then, 3 cm of the ureter was mobilized by pushing the adherent peritoneum away using a small dissector and a monopolar hook. The next step of the Politano–Leadbetter technique differs from that of the Cohen technique. To create a new hiatus in the bladder mucosa, an incision was made 2–3 cm superior to the original hiatus. The length was measured using a 5-Fr ureteral catheter that had been inserted from the urethral meatus (Fig. 2) to carry out the Politano–Leadbetter technique. Both hiatuses were elevated with clamps. To safely separate the ureter from connective tissue around the posterior bladder wall, the cystoscope was inserted through the new hiatus, and the ureter was carefully dissected under cystoscopic vision (Fig. 3). The dissector could be viewed through the adventitial soft tissue when the peritoneum was sufficiently mobilized. Using miniature endoscissors, the residual muscle and adventitial © 2015 The Japanese Urological Association
Pneumovesicum approach for ureteral reimplantation
Table 2 Results of transvesical pneumovesicum ureteral reimolantation Case no.
Procedure
Surgical side
Operative time* (min)
Catheter†
Hospital stay‡
Follow up (months)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Politano–Leadbetter Politano–Leadbetter Politano–Leadbetter Politano–Leadbetter Politano–Leadbetter Politano–Leadbetter Cohen Cohen Cohen Cohen Cohen Cohen Politano–Leadbetter Politano–Leadbetter Cohen Cohen Cohen Cohen Cohen Cohen Politano–Leadbetter Politano–Leadbetter Politano–Leadbetter Politano–Leadbetter
Right Left Right Bil Bil Left Right Right Bil Bil Bil Bil Bil Bil Right Left Bil Left Bil Bil Right Bil Bil Bil
288 300 210 342 324 318 212 235 268 264 306 268 360 426 205 238 286 236 210 295 208 267 240 318
2 2 2 2 2 2 2 3 2 3 2 2 3 3 2 2 3 3 1 4 2 2 3 2
3 3 3 7 3 3 3 4 3 2 3 3 5 4 2 3 2 8 3 5 4 3 3 3
81 80 78 77 77 73 73 66 62 55 53 50 48 42 26 24 21 18 13 9 5 2 2 2
Complication
Grade 3
Grade 1
Follow up VCUG Resolved Resolved Resolved Resolved Persist grade I VUR Urine leakage Resolved Persist grade I VUR Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved
†Postoperative indwelling catheter days. ‡Postoperative hospital stay days. *There is a significant difference in operation time between Cohen and Politano– Leadbetter (P < 0.05)
Fig. 1 Lifting the suture line allows circumferential cutting of the bladder epithelium and Waldeyer sheath around the orifice.
tissue were dissected and cut toward the dissector along the posterior bladder wall when the ureter was identified just below the newly created hiatus. The ureter was pulled through the tunnel and out through the new hiatus. The defect in the bladder wall, behind the original hiatus, was closed with continuous 5-0 absorbable sutures. © 2015 The Japanese Urological Association
Fig. 2 The position of the new hiatus is marked using electrocautery at 2.5–3 cm cephalad to the original hiatus.
After repair of the bladder wall, a subepithelial tunnel was created from the original hiatus to the new hiatus by cutting and spreading with miniature endoscissors through the second and third ports or urethra (Fig. 4). The ureter was then pulled through the new tunnel to the original hiatus and anastomosed to the old hiatus (Fig. 5). If additional length was required for 3
S SOH ET AL.
Fig. 3 To create a new hiatus, the dissector is gently inserted into the hiatus and slid along the outer surface of the bladder wall. To ensure safe maneuvering, clamps pull tightly on and elevate the bladder wall at the edges of the new and old hiatus. The structure of the outer bladder wall can be seen with cystoscopy.
Fig. 5 The ureter is then pulled through the new tunnel to the original hiatus and anastomosed to the old hiatus. If the ureter needs additional length, the tunnel can be advanced distally.
cystourethrography and DMSA renal scanning. In addition, patients underwent repeated postoperative urinalysis and ultrasound examinations. To confirm postoperative resolution of VUR, all patients were scheduled for voiding cystourethrography at 2–4 months postoperatively.
Statistical analysis The Mann–Whitney U-test was used to compare operative time between patients treated with the Politano–Leadbetter and Cohen techniques. Fisher’s exact test was used to compare the VUR resolution rate. All analysis was carried out using the IBM SPSS software package (IBM, Armonk, NY, USA).
Results
Fig. 4 After passing the ureter out through the bladder wall and in through the new hiatus, a submucosal tunnel is created by using miniature endoscissors.
the ureter, the tunnel was advanced distally to accommodate a new orifice. The ureter was fixed with six to eight sutures. The first two sutures were placed deep in the trigonal muscle, through the vesical epithelium and muscle, using 5-0 absorbable sutures. A 4-Fr infant feeding tube was passed into the ureter to confirm the absence of ureteral kinking, and kept in place until the next morning in patients who underwent bilateral ureteral reimplantation. The upper epithelium incision was closed vertically with absorbable sutures. The Foley catheter was removed on the second day after surgery. A total of 12 female patients underwent transvesicoscopic Cohen ureteral reimplantation, which was carried out as previously described.2
Follow up To evaluate VUR and renal scarring, all patients underwent preoperative urinalysis, uroflowmetry, ultrasound, voiding 4
The median operative time for the remaining 24 cases was 268 ± 62 min (median ± standard deviation), not including the time required for any additional required procedures (Tables 1, 3). Overall operative time was longer for the Politano–Leadbetter technique (overall 305 ± 74 min; bilateral procedures 324 ± 77 min; unilateral procedures 288 ± 52 min) than for the Cohen technique (overall 251 ± 34 min; bilateral procedures 268 ± 31 min; unilateral procedures 235 ± 15 min). The difference was approximately Table 3 Comparison results between transvesicoscopic ureteral reimplantation Politano–Leadbetter and Cohen techniques Politano–Leadbetter Cohen P-value (n = 12) (n = 12) Median age (years) Median operation time (min) Single (min) Bilateral (min) Mean indwelling catheter days Mean postoperative hospital stay VUR resolution (%)
9 305 288 324 2.3 3.7 94.4
15 251 235 268 2.4 3.4 94.7
International Journal of Urology (2015)
doi: 10.1111/iju.12702
Original Article
Transvesicoscopic ureteral reimplantation: Politano–Leadbetter versus Cohen technique Shigehiro Soh,1 Yoshitomo Kobori,1 Takeshi Shin,1 Keisuke Suzuki,1 Toshiyuki Iwahata,1 Yuko Sadaoka,1 Ryo Sato,1 Morihiro Nishi,2 Masatsugu Iwamura2 and Hiroshi Okada1 1
Department of Urology, Dokkyo Medical University Koshigaya Hospital, Koshigaya, and 2Kitasato University School of Medicine, Sagamihara, Japan Abbreviations & Acronyms Bil = bilateral DMSA = dimercaptosuccinic acid OAB = overactive bladder VCUG = voiding cystourethragrapy VUJO = vesicoureteral obstruction VUR = vesicoureteral reflux Correspondence: Shigehiro Soh M.D., Ph.D., Department of Urology, Dokkyo Medical University Koshigaya Hospital, 2-1-50 Minami-Koshigaya, Koshigaya 343-8555, Japan. Email: [email protected] Received 27 August 2014; accepted 3 December 2014.
Objectives: To compare the outcomes of the Politano–Leadbetter and Cohen techniques in laparoscopic pneumovesicum approach for ureteral reimplantation. Methods: We retrospectively reviewed the medical records of 24 patients who underwent transvesicoscopic ureteral reimplantation during the period from 2007 to 2014. The patients were treated with either the Cohen or Politano–Leadbetter technique. Operative duration, duration of hospital stay, and success and complication rates were compared. Results: Operative duration was 1 h longer for the Politano–Leadbetter technique than for the Cohen technique (P < 0.05). Foley catheters were removed 2–3 days after the procedures. The mean hospital stay was 3.6 days. Reflux completely resolved in 21 patients (35 ureters, 94.6%), but not in two patients (2 ureters). There was no difference in the success rate or durations of catheterization or hospital stay between patients treated with the Politano–Leadbetter technique and those treated with the Cohen technique. Conclusions: The Politano–Leadbetter and Cohen techniques are both reliable for transvesicoscopic ureteral reimplantation. Despite a longer operative time, because of the higher surgical complexity, the Politano–Leadbetter ureteral reimplantation offers important physiological advantages over other techniques.
Key words:
laparoscopic, pneumovesicum, transvesical, ureteral reimplantation, vesicoureteral
reflux.
Introduction Laparoscopic surgical techniques have replaced open surgical management for a number of pediatric urological conditions. Minimally invasive surgical procedures using these techniques have been shown to be effective in managing VUR in children. Lakshmanan et al. were the first to describe laparoscopic extravesical reimplantation in humans.1 Since then, a number of endoscopic and laparoscopic ureteral reimplantation techniques have been developed to treat VUR and vesicoureteral junction obstruction.1–14 A novel minimally invasive cross-trigonal ureteral reimplantation technique under pneumovesicum, reported by Yeung, is now widespread and has better success rates than open cross-trigonal reimplantation.2 The transvesicoscopic Cohen technique for cross-trigonal ureteral reimplantation has been frequently described; however, there have been no reports regarding the Politano–Leadbetter technique.2–7 The theoretical advantages of ureteral reimplantation using the Politano–Leadbetter technique include the ability to create a long tunnel and carry out retrograde catheterization through the normal ureteral orifice.15 However, the difficulty of creating a new cephalad hiatus has slowed uptake of this procedure among surgeons. We used two intravesical techniques during this study period, and developed a new method that uses a laparoscopic pneumovesicum approach for the Politano–Leadbetter and Cohen techniques. We describe the details of this new method and retrospectively review our outcomes with these two techniques.
Methods Patients We retrospectively reviewed the medical records of patients who underwent ureteral reimplantation surgery during the period from 2007 to 2014. The study was carried out as a © 2015 The Japanese Urological Association
1
S SOH ET AL.
clinical trial (no. 1424) under the supervision of physicians at Dokkyo Medical University Koshigaya Hospital, Koshigaya, Japan, after approval from the institutional review board had been obtained. On the basis of our experience, female patients older than 4 years with a bladder capacity greater than 200 mL (as determined by vesicourethral cystography) were considered suitable candidates for the pneumovesicum technique. All patients (or parents, in the case of pediatric patients) were asked if they preferred laparoscopic surgery; however, the present study includes only those who chose transvesicoscopic ureteral reimplantation. A total of 23 female patients with persistent primary grade II–IV VUR (Table 1) were offered various management options, and selected and gave informed consent for pneumovesicum ureteral reimplantation. All surgeries were carried out by the same surgeon (SS). Among the 24 patients, 12 were treated with the Politano–Leadbetter technique and 12 were treated with the Cohen technique. One girl with vesicoureteral junction obstruction and symptomatic ureteral calculi also selected this procedure. She underwent transvesicoscopic ureteral reimplantation by the Politano– Leadbetter technique without ureteral tailoring, because the dilatation of the ureter was mild. The technique was randomly selected, except for one girl who had vesicoureteral junction obstruction. The median patient age was 10 years (range 4–38 years). However, the procedure was not selected by the patient’s age, and there was a difference in median age between the Politano–Leadbetter and Cohen technique (Tables 2, 3). Six of the 23 patients with VUR (26%) had urgent incontinence, and nine (39%) had constipation. Any patients with associated symptoms of overactive bladder received Table 1 Patients’ characteristics Case no.
Age (years)
Urgent†
Constipation
Febrile UTI‡
Renal scarring
VUR grade (left/right)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
10 6 9 5 4 10 23 29 9 25 17 11 7 6 15 4 38 7 8 38 17 10 9 19
None None None Yes None None None Yes None Yes None None Yes None None None Yes None None Yes Yes None None None
None None None Yes None None None Yes None Yes None None Yes None Yes None Yes None None Yes None Yes None Yes
Yes Yes None Yes Yes None Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes None Yes None None Yes Yes Yes Yes None Yes None Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
4/– –/3 VUJO/– 3/2 2/4 2/3 3/– 3/– 4/4 –/3 3/3 3/3 4/2 1/3 2/– –/4 3/2 2/– 1/3 3/2 3/– 3/4 3/3 3/1
†Urgent sense or incontinence. ‡Constipation, febrile urinary tract infection.
2
appropriate management, including a voiding diary, timed voiding and anticholinergic agents, before surgery was considered. In addition, patients with bowel dysfunction were treated with stool softeners and laxatives. Of the 23 patients with VUR, 22 had a breakthrough urinary tract infection and/or multiple pyelonephritic renal scars on DMSA renal scanning. Two patients who developed a recurrence after endoscopic treatment with Deflux or collagen were included in the study: one underwent transvesicoscopic Cohen reimplantation and the other was treated using the Politano–Leadbetter technique.
Surgical techniques The pneumovesicum Politano–Leadbetter technique was carried out using an original method. As in previous reports, the bladder was distended with saline during cystoscopic examination and was fixed percutaneously to the abdominal wall with 20 absorbable sutures.2 A midline was established between the umbilicus and the top of the pubic bone. An 8-mm incision was then made in the abdominal wall, 1 cm below the midline. Then, an 18-G needle was passed through the incision into the bladder, and a 3-0 absorbable suture was threaded through the needle and left in place. Another 18-G needle was then passed through an adjacent puncture in the bladder, through which a looped suture was inserted into the bladder. Using the biopsy forceps of the cystoscope, the suture was retrieved, pulled through the loop of the suture and extracted. The suture was then tied and pulled up, to stretch the bladder wall, while a 5mm step port for the camera was inserted into the bladder. After percutaneous fixation of the first port, the second and third ports were made in the abdominal wall in the same manner, 2.5– 3.0 cm lateral to the first port, on both sides. We used a 3-mm port for left-hand maneuvers and a 5-mm port for right-hand maneuvers. After the port placements, we drained the saline solution and inflated the bladder with gas. The insufflation pressure of CO2 was 8 mm Hg. A 4-cm–long ureteral stent tube was prepared from a 4-Fr infant feeding tube. The stent tube was inserted into a ureteral orifice and fixed with a 5-0 absorbable suture placed below the ureteral orifice. Lifting the suture line allows circumferential cutting of the bladder epithelium and the Waldeyer sheath around the orifice, using miniature endoscissors and a monopolar hook (Fig. 1). To free the ureter from the bladder wall, a plane was then developed between the bladder muscle and ureteral adventitia. Then, 3 cm of the ureter was mobilized by pushing the adherent peritoneum away using a small dissector and a monopolar hook. The next step of the Politano–Leadbetter technique differs from that of the Cohen technique. To create a new hiatus in the bladder mucosa, an incision was made 2–3 cm superior to the original hiatus. The length was measured using a 5-Fr ureteral catheter that had been inserted from the urethral meatus (Fig. 2) to carry out the Politano–Leadbetter technique. Both hiatuses were elevated with clamps. To safely separate the ureter from connective tissue around the posterior bladder wall, the cystoscope was inserted through the new hiatus, and the ureter was carefully dissected under cystoscopic vision (Fig. 3). The dissector could be viewed through the adventitial soft tissue when the peritoneum was sufficiently mobilized. Using miniature endoscissors, the residual muscle and adventitial © 2015 The Japanese Urological Association
Pneumovesicum approach for ureteral reimplantation
Table 2 Results of transvesical pneumovesicum ureteral reimolantation Case no.
Procedure
Surgical side
Operative time* (min)
Catheter†
Hospital stay‡
Follow up (months)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Politano–Leadbetter Politano–Leadbetter Politano–Leadbetter Politano–Leadbetter Politano–Leadbetter Politano–Leadbetter Cohen Cohen Cohen Cohen Cohen Cohen Politano–Leadbetter Politano–Leadbetter Cohen Cohen Cohen Cohen Cohen Cohen Politano–Leadbetter Politano–Leadbetter Politano–Leadbetter Politano–Leadbetter
Right Left Right Bil Bil Left Right Right Bil Bil Bil Bil Bil Bil Right Left Bil Left Bil Bil Right Bil Bil Bil
288 300 210 342 324 318 212 235 268 264 306 268 360 426 205 238 286 236 210 295 208 267 240 318
2 2 2 2 2 2 2 3 2 3 2 2 3 3 2 2 3 3 1 4 2 2 3 2
3 3 3 7 3 3 3 4 3 2 3 3 5 4 2 3 2 8 3 5 4 3 3 3
81 80 78 77 77 73 73 66 62 55 53 50 48 42 26 24 21 18 13 9 5 2 2 2
Complication
Grade 3
Grade 1
Follow up VCUG Resolved Resolved Resolved Resolved Persist grade I VUR Urine leakage Resolved Persist grade I VUR Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved
†Postoperative indwelling catheter days. ‡Postoperative hospital stay days. *There is a significant difference in operation time between Cohen and Politano– Leadbetter (P < 0.05)
Fig. 1 Lifting the suture line allows circumferential cutting of the bladder epithelium and Waldeyer sheath around the orifice.
tissue were dissected and cut toward the dissector along the posterior bladder wall when the ureter was identified just below the newly created hiatus. The ureter was pulled through the tunnel and out through the new hiatus. The defect in the bladder wall, behind the original hiatus, was closed with continuous 5-0 absorbable sutures. © 2015 The Japanese Urological Association
Fig. 2 The position of the new hiatus is marked using electrocautery at 2.5–3 cm cephalad to the original hiatus.
After repair of the bladder wall, a subepithelial tunnel was created from the original hiatus to the new hiatus by cutting and spreading with miniature endoscissors through the second and third ports or urethra (Fig. 4). The ureter was then pulled through the new tunnel to the original hiatus and anastomosed to the old hiatus (Fig. 5). If additional length was required for 3
S SOH ET AL.
Fig. 3 To create a new hiatus, the dissector is gently inserted into the hiatus and slid along the outer surface of the bladder wall. To ensure safe maneuvering, clamps pull tightly on and elevate the bladder wall at the edges of the new and old hiatus. The structure of the outer bladder wall can be seen with cystoscopy.
Fig. 5 The ureter is then pulled through the new tunnel to the original hiatus and anastomosed to the old hiatus. If the ureter needs additional length, the tunnel can be advanced distally.
cystourethrography and DMSA renal scanning. In addition, patients underwent repeated postoperative urinalysis and ultrasound examinations. To confirm postoperative resolution of VUR, all patients were scheduled for voiding cystourethrography at 2–4 months postoperatively.
Statistical analysis The Mann–Whitney U-test was used to compare operative time between patients treated with the Politano–Leadbetter and Cohen techniques. Fisher’s exact test was used to compare the VUR resolution rate. All analysis was carried out using the IBM SPSS software package (IBM, Armonk, NY, USA).
Results
Fig. 4 After passing the ureter out through the bladder wall and in through the new hiatus, a submucosal tunnel is created by using miniature endoscissors.
the ureter, the tunnel was advanced distally to accommodate a new orifice. The ureter was fixed with six to eight sutures. The first two sutures were placed deep in the trigonal muscle, through the vesical epithelium and muscle, using 5-0 absorbable sutures. A 4-Fr infant feeding tube was passed into the ureter to confirm the absence of ureteral kinking, and kept in place until the next morning in patients who underwent bilateral ureteral reimplantation. The upper epithelium incision was closed vertically with absorbable sutures. The Foley catheter was removed on the second day after surgery. A total of 12 female patients underwent transvesicoscopic Cohen ureteral reimplantation, which was carried out as previously described.2
Follow up To evaluate VUR and renal scarring, all patients underwent preoperative urinalysis, uroflowmetry, ultrasound, voiding 4
The median operative time for the remaining 24 cases was 268 ± 62 min (median ± standard deviation), not including the time required for any additional required procedures (Tables 1, 3). Overall operative time was longer for the Politano–Leadbetter technique (overall 305 ± 74 min; bilateral procedures 324 ± 77 min; unilateral procedures 288 ± 52 min) than for the Cohen technique (overall 251 ± 34 min; bilateral procedures 268 ± 31 min; unilateral procedures 235 ± 15 min). The difference was approximately Table 3 Comparison results between transvesicoscopic ureteral reimplantation Politano–Leadbetter and Cohen techniques Politano–Leadbetter Cohen P-value (n = 12) (n = 12) Median age (years) Median operation time (min) Single (min) Bilateral (min) Mean indwelling catheter days Mean postoperative hospital stay VUR resolution (%)
9 305 288 324 2.3 3.7 94.4
15 251 235 268 2.4 3.4 94.7
