Opposing Views
Ureteral Reimplantation in Adults: Open Versus Robotic OPEN INDICATIONS for adult ureteral reimplantation include extirpation of malignancy, iatrogenic injury and benign stricture disease. Causes of iatrogenic ureteral injury include complications of gynecologic surgery (hysterectomy), colorectal surgery (low anterior resection and abdominoperineal resection) and urological surgery (ureteroscopy and prostatectomy). Causes of benign ureteral stricture include retroperitoneal fibrosis secondary to vascular bypass grafting and radiation. The definitive management of ureteral strictures and ureteral injury is a common reconstructive problem that the urologist must manage, as endoscopic techniques have marginal long-term success rates. When the distal ureter cannot be reimplanted directly into the bladder due to insufficient length, ancillary techniques are required, which include a psoas hitch and Boari flap. The question has been asked as to whether open or robotic surgery is the optimal method to manage ureteral reimplantation. The psoas hitch was originally described by Witzel in 1896 but did not gain popularity until the work of Zimmerman and Turner-Warwick in the 1960s.1 While the Boari flap was initially used in an animal model in 1894, it was not described in humans until 1947.2 Now with more than 50 years of open surgical experience, the data on open reconstructive outcomes are mature. Single center series with as many as 181 patients at 4.5 years of followup document a 97% success rate.3 In the last 20 years our field has witnessed the evolution and application of minimally invasive surgery to urology, starting with laparoscopy and progressing to robotic assisted surgery. Robotic assisted surgery has been used for prostate cancer, renal cancer and bladder cancer. As with any new surgical approach, comparison to established techniques must be made to assess outcomes, complications and costeffectiveness. Although these data are most mature for prostatectomy, they are still developing for ureteral reconstruction. Our current best level of evidence to compare robotic to open surgical distal ureteral reconstruction is level 3b, based on a case control study by Kozinn et al comparing 10 robotic
0022-5347/14/1924-1023/0 THE JOURNAL OF UROLOGY® © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
to 24 open ureteral reimplants.4 Statistically significant findings including less blood loss and shorter hospital stay favored the robotic approach but there was no significant difference in decreased narcotic use between the groups. Furthermore, not every patient is a robotic candidate. Surgical history, obesity and inability to tolerate the Trendelenburg position are common relative contraindications to robotic surgery. My personal bias for open reconstruction pertains to the concept of surgical versatility. Surgical reconstruction requires more intraoperative decision making relative to many operations in urology. Despite adequate preoperative antegrade imaging, retrograde imaging and bladder capacity evaluation, defect length and anastomotic tension are most accurately assessed intraoperatively. Tactile feedback for tension is lost with robotic surgery. When tension and length for anastomosis are an issue, surgical ancillary maneuvers are required, which are more easily accomplished through an open incision relative to a robotic approach when the trocars are directed at the pelvis. Mauck et al showed that upper ureteral strictures can be adequately managed with a psoas hitch, Boari flap and downward nephropexy of the ipsilateral renal unit.5 The downward nephropexy can result in an extra 4 to 7 cm of ureteral length for the anastomosis. Other options for upper ureteral reconstruction are transureteral ureterostomy, creation of an ileal ureter, ureterocalicostomy and autotransplant. These procedures can be accomplished readily through an open incision, and would be a challenge to accomplish robotically without repositioning the patient or inserting additional ports. Although time may reveal that open and robotic approaches to distal ureteral re-implantation are equivalent, presently there is insufficient evidence to support this contention. An open surgical approach remains the gold standard. Ideally, a randomized controlled trial would be required to define equivalence between the 2 procedures. Christopher McClung Department of Urology Ohio State University Medical Center Columbus, Ohio
http://dx.doi.org/10.1016/j.juro.2014.07.020 Vol. 192, 1023-1025, October 2014 Printed in U.S.A.
www.jurology.com
j
1023
1024
OPPOSING VIEWS
ROBOTIC Reconstruction of the distal ureter is typically accomplished with ureteral reimplantation into the bladder based on anatomic and technical considerations. While not commonly performed, ureteral reimplantation is an essential skill for urologists to master because it may need to be performed in an emergent setting following an iatrogenic injury. It is also used for distal ureteral tumors and benign strictures due to various etiologies. Traditionally, the open surgical approach to ureteral reimplantation has performed. However, since 2003 when the first robotic reimplantation was performed by Yohannes et al, the robotic approach has been increasingly used.1 There are many distinct advantages to using the da VinciÒ robotic surgical system to perform distal ureteral reimplantation, many of which are inherent to all robotic procedures. First, surgeons are able to work in the deep pelvis with good visualization and 3-D magnification. Second, precise intracorporeal suturing can be performed in a favorable environment. Finally, the pneumoperitoneum provides a hemostatic advantage to further improve visualization and limit blood loss. Unfortunately, because ureteral reimplantation is rarely performed, there is a paucity of evidence to support its use over traditional open surgery. Nonetheless, because of the aforementioned advantages, the adoption of robotic surgery for reconstruction has continued despite the absence of a robust evidence base suggesting superior outcomes. The guiding principle with adoption of any minimally invasive technique in urology has been and should remain absolute abidance of the principles of open surgery and replication of open surgery results. The technical aspects of this operation include tension-free and watertight anastomosis with mucosal approximation of viable tissue. A surgeon performing reimplantation (with any approach) should also be able to perform a psoas hitch and Boari flap if necessary to fulfill the above reconstructive requirements. In this context, there is a small but growing body of evidence that suggests at least equivalent outcomes between open and robotic reimplantation surgery. More than a dozen articles have been published in the last decade on outcomes of greater than 100 patients undergoing robotic ureteroneocystotomy.4,6e9 There have been few comparative effectiveness studies of open versus robotic reimplantation approaches.4,7e9 Most of these case series were associated with success rates approaching 100% with few complications. Kozinn et al retrospectively compared 10 consecutive robotic reimplants in a case control fashion.4 They
demonstrated significant improvement in blood loss and length of stay and, while length of surgery was longer in the robotic group, the difference was not statistically significant. The criticisms against the use of the robot are the infrequent need for open conversion and longer operating times. However, open conversions can be attributed to the disease process since many of these operations are performed after previous abdominal or pelvic surgery. Additionally, the likelihood of conversion to open surgery and operating times will improve as surgeons ascend the learning curve, similar to what occurred with other, more common robotic procedures. Some of the practice applicable to reimplantation comes from other surgical procedures. For example, the release of the bladder is now a standard part of the robotic radical prostatectomy procedure. Robotic cystectomy is also widely performed at many centers, and ureteral mobilization and anastomosis are just two of many steps of this complex operation. The theoretical argument, which is increased cost, against robotic surgery is a moot point today since most centers in the United States own the robot for which a maintenance fee is paid whether or not it is used. The increased cost associated with robotic instruments can at least be partially offset by the decreased hospital stay and quicker return to work associated with minimally invasive surgery. Ideally, a randomized, multi-institutional, clinical trial will be conducted to compare the 2 approaches. The initial research objective with adoption of any new procedure is to demonstrate equivalency of outcome and complication rates. Collectively, the growing body of observational studies demonstrates at least equivalent results between open and robotic ureteral reimplantation surgery. Given that both approaches have equivalent results, the advantages of better visualization, precise suturing and improved hemostasis make the robotic approach ideal for a urologist competent in robotic surgery. While we await a randomized clinical trial, we should continue to develop and evolve the robotic approach to ureteral reimplantation. Ultimately, I am confident that the robotic approach will demonstrate superiority over its open counterpart in the near future, similar to the transformation that occurred to the operative approach to upper ureteral reconstruction for ureteropelvic junction obstruction, for which minimally invasive repair has now become the gold standard. Alex Gorbonos Department of Urology Loyola University Maywood, Illinois
OPPOSING VIEWS
1025
REFERENCES 1. Warwick RT and Worth PH: The psoas bladderhitch procedure for the replacement of the lower third of the ureter. Br J Urol 1969; 41: 701.
reimplantation for benign stricture disease. J Endourol 2012; 26: 147.
ureter: single institution experience in 16 patients. BJU Int 2013; 111: 773.
2. Ockerblad NF: Reimplantation of the ureter into the bladder by a flap method. J Urol 1947; 57: 845.
5. Mauck RJ, Hudak SJ, Terlecki RP et al: Central role of Boari bladder flap and downward nephropexy in upper ureteral reconstruction. J Urol 2011; 186: 1345.
3. Riedmiller H, Becht E, Hertle L et al: Psoas-hitch ureteroneocystostomy: experience with 181 cases. Eur Urol 1984; 10: 145.
6. Stanasel I, Atala A and Hemal A: Robotic assisted ureteral reimplantation: current status. Curr Urol Rep 2013; 14: 32.
8. Baldie K, Angell J, Ogan K et al: Robotic management of benign mid and distal ureteral strictures and comparison with laparoscopic approaches at a single institution. Urology 2012; 80: 596.
4. Kozinn SI, Canes D, Sorcini A et al: Robotic versus open distal ureteral reconstruction and
7. Musch M, Hohenhorst L, Pailliart A et al: Robotassisted reconstructive surgery of the distal
9. Patil N, Mottrie A, Sundaram B et al: Roboticassisted laparoscopic ureteral reimplantation with psoas hitch: a multi-institutional, multinational evaluation. Urology 2008; 72: 47.
Ureteral Reimplantation in Adults: Open Versus Robotic OPEN INDICATIONS for adult ureteral reimplantation include extirpation of malignancy, iatrogenic injury and benign stricture disease. Causes of iatrogenic ureteral injury include complications of gynecologic surgery (hysterectomy), colorectal surgery (low anterior resection and abdominoperineal resection) and urological surgery (ureteroscopy and prostatectomy). Causes of benign ureteral stricture include retroperitoneal fibrosis secondary to vascular bypass grafting and radiation. The definitive management of ureteral strictures and ureteral injury is a common reconstructive problem that the urologist must manage, as endoscopic techniques have marginal long-term success rates. When the distal ureter cannot be reimplanted directly into the bladder due to insufficient length, ancillary techniques are required, which include a psoas hitch and Boari flap. The question has been asked as to whether open or robotic surgery is the optimal method to manage ureteral reimplantation. The psoas hitch was originally described by Witzel in 1896 but did not gain popularity until the work of Zimmerman and Turner-Warwick in the 1960s.1 While the Boari flap was initially used in an animal model in 1894, it was not described in humans until 1947.2 Now with more than 50 years of open surgical experience, the data on open reconstructive outcomes are mature. Single center series with as many as 181 patients at 4.5 years of followup document a 97% success rate.3 In the last 20 years our field has witnessed the evolution and application of minimally invasive surgery to urology, starting with laparoscopy and progressing to robotic assisted surgery. Robotic assisted surgery has been used for prostate cancer, renal cancer and bladder cancer. As with any new surgical approach, comparison to established techniques must be made to assess outcomes, complications and costeffectiveness. Although these data are most mature for prostatectomy, they are still developing for ureteral reconstruction. Our current best level of evidence to compare robotic to open surgical distal ureteral reconstruction is level 3b, based on a case control study by Kozinn et al comparing 10 robotic
0022-5347/14/1924-1023/0 THE JOURNAL OF UROLOGY® © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
to 24 open ureteral reimplants.4 Statistically significant findings including less blood loss and shorter hospital stay favored the robotic approach but there was no significant difference in decreased narcotic use between the groups. Furthermore, not every patient is a robotic candidate. Surgical history, obesity and inability to tolerate the Trendelenburg position are common relative contraindications to robotic surgery. My personal bias for open reconstruction pertains to the concept of surgical versatility. Surgical reconstruction requires more intraoperative decision making relative to many operations in urology. Despite adequate preoperative antegrade imaging, retrograde imaging and bladder capacity evaluation, defect length and anastomotic tension are most accurately assessed intraoperatively. Tactile feedback for tension is lost with robotic surgery. When tension and length for anastomosis are an issue, surgical ancillary maneuvers are required, which are more easily accomplished through an open incision relative to a robotic approach when the trocars are directed at the pelvis. Mauck et al showed that upper ureteral strictures can be adequately managed with a psoas hitch, Boari flap and downward nephropexy of the ipsilateral renal unit.5 The downward nephropexy can result in an extra 4 to 7 cm of ureteral length for the anastomosis. Other options for upper ureteral reconstruction are transureteral ureterostomy, creation of an ileal ureter, ureterocalicostomy and autotransplant. These procedures can be accomplished readily through an open incision, and would be a challenge to accomplish robotically without repositioning the patient or inserting additional ports. Although time may reveal that open and robotic approaches to distal ureteral re-implantation are equivalent, presently there is insufficient evidence to support this contention. An open surgical approach remains the gold standard. Ideally, a randomized controlled trial would be required to define equivalence between the 2 procedures. Christopher McClung Department of Urology Ohio State University Medical Center Columbus, Ohio
http://dx.doi.org/10.1016/j.juro.2014.07.020 Vol. 192, 1023-1025, October 2014 Printed in U.S.A.
www.jurology.com
j
1023
1024
OPPOSING VIEWS
ROBOTIC Reconstruction of the distal ureter is typically accomplished with ureteral reimplantation into the bladder based on anatomic and technical considerations. While not commonly performed, ureteral reimplantation is an essential skill for urologists to master because it may need to be performed in an emergent setting following an iatrogenic injury. It is also used for distal ureteral tumors and benign strictures due to various etiologies. Traditionally, the open surgical approach to ureteral reimplantation has performed. However, since 2003 when the first robotic reimplantation was performed by Yohannes et al, the robotic approach has been increasingly used.1 There are many distinct advantages to using the da VinciÒ robotic surgical system to perform distal ureteral reimplantation, many of which are inherent to all robotic procedures. First, surgeons are able to work in the deep pelvis with good visualization and 3-D magnification. Second, precise intracorporeal suturing can be performed in a favorable environment. Finally, the pneumoperitoneum provides a hemostatic advantage to further improve visualization and limit blood loss. Unfortunately, because ureteral reimplantation is rarely performed, there is a paucity of evidence to support its use over traditional open surgery. Nonetheless, because of the aforementioned advantages, the adoption of robotic surgery for reconstruction has continued despite the absence of a robust evidence base suggesting superior outcomes. The guiding principle with adoption of any minimally invasive technique in urology has been and should remain absolute abidance of the principles of open surgery and replication of open surgery results. The technical aspects of this operation include tension-free and watertight anastomosis with mucosal approximation of viable tissue. A surgeon performing reimplantation (with any approach) should also be able to perform a psoas hitch and Boari flap if necessary to fulfill the above reconstructive requirements. In this context, there is a small but growing body of evidence that suggests at least equivalent outcomes between open and robotic reimplantation surgery. More than a dozen articles have been published in the last decade on outcomes of greater than 100 patients undergoing robotic ureteroneocystotomy.4,6e9 There have been few comparative effectiveness studies of open versus robotic reimplantation approaches.4,7e9 Most of these case series were associated with success rates approaching 100% with few complications. Kozinn et al retrospectively compared 10 consecutive robotic reimplants in a case control fashion.4 They
demonstrated significant improvement in blood loss and length of stay and, while length of surgery was longer in the robotic group, the difference was not statistically significant. The criticisms against the use of the robot are the infrequent need for open conversion and longer operating times. However, open conversions can be attributed to the disease process since many of these operations are performed after previous abdominal or pelvic surgery. Additionally, the likelihood of conversion to open surgery and operating times will improve as surgeons ascend the learning curve, similar to what occurred with other, more common robotic procedures. Some of the practice applicable to reimplantation comes from other surgical procedures. For example, the release of the bladder is now a standard part of the robotic radical prostatectomy procedure. Robotic cystectomy is also widely performed at many centers, and ureteral mobilization and anastomosis are just two of many steps of this complex operation. The theoretical argument, which is increased cost, against robotic surgery is a moot point today since most centers in the United States own the robot for which a maintenance fee is paid whether or not it is used. The increased cost associated with robotic instruments can at least be partially offset by the decreased hospital stay and quicker return to work associated with minimally invasive surgery. Ideally, a randomized, multi-institutional, clinical trial will be conducted to compare the 2 approaches. The initial research objective with adoption of any new procedure is to demonstrate equivalency of outcome and complication rates. Collectively, the growing body of observational studies demonstrates at least equivalent results between open and robotic ureteral reimplantation surgery. Given that both approaches have equivalent results, the advantages of better visualization, precise suturing and improved hemostasis make the robotic approach ideal for a urologist competent in robotic surgery. While we await a randomized clinical trial, we should continue to develop and evolve the robotic approach to ureteral reimplantation. Ultimately, I am confident that the robotic approach will demonstrate superiority over its open counterpart in the near future, similar to the transformation that occurred to the operative approach to upper ureteral reconstruction for ureteropelvic junction obstruction, for which minimally invasive repair has now become the gold standard. Alex Gorbonos Department of Urology Loyola University Maywood, Illinois
OPPOSING VIEWS
1025
REFERENCES 1. Warwick RT and Worth PH: The psoas bladderhitch procedure for the replacement of the lower third of the ureter. Br J Urol 1969; 41: 701.
reimplantation for benign stricture disease. J Endourol 2012; 26: 147.
ureter: single institution experience in 16 patients. BJU Int 2013; 111: 773.
2. Ockerblad NF: Reimplantation of the ureter into the bladder by a flap method. J Urol 1947; 57: 845.
5. Mauck RJ, Hudak SJ, Terlecki RP et al: Central role of Boari bladder flap and downward nephropexy in upper ureteral reconstruction. J Urol 2011; 186: 1345.
3. Riedmiller H, Becht E, Hertle L et al: Psoas-hitch ureteroneocystostomy: experience with 181 cases. Eur Urol 1984; 10: 145.
6. Stanasel I, Atala A and Hemal A: Robotic assisted ureteral reimplantation: current status. Curr Urol Rep 2013; 14: 32.
8. Baldie K, Angell J, Ogan K et al: Robotic management of benign mid and distal ureteral strictures and comparison with laparoscopic approaches at a single institution. Urology 2012; 80: 596.
4. Kozinn SI, Canes D, Sorcini A et al: Robotic versus open distal ureteral reconstruction and
7. Musch M, Hohenhorst L, Pailliart A et al: Robotassisted reconstructive surgery of the distal
9. Patil N, Mottrie A, Sundaram B et al: Roboticassisted laparoscopic ureteral reimplantation with psoas hitch: a multi-institutional, multinational evaluation. Urology 2008; 72: 47.
