Journal of Pediatric Urology (2012) 8, 268e271

Robotic-assisted laparoscopic extravesical ureteralreimplantation: An initial experience

David Chalmers a,*, Katherine Herbst b, Christina Kim c

aDepartment of Urology, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030, USAbConnecticut Children’s Medical Center, 282 Washington Street, Hartford, CT 06106, USAcDepartment of Pediatric Urology, Connecticut Children’s Medical Center, 282 Washington Street, Hartford, CT 06106, USA

Received 6 December 2010; accepted 6 April 2011Available online 8 June 2011

KEYWORDSVesicoureteral reflux;Robotic-assistedlaparoscopy;Pediatric

* Corresponding author. Tel.: 1 860E-mail addresses: dchalmers@resid

1477-5131/$36 ª 2011 Journal of Peddoi:10.1016/j.jpurol.2011.04.006

Abstract Objective: There are many emerging techniques using robotic-assisted laparoscopy(RAL) in pediatrics. We performed a retrospective review of our first patients who underwentRAL extravesical ureteral reimplantation.Materials/Methods: Between October 2007 and May 2010, a single surgeon performed RAL ex-travesical ureteral reimplantation in 17 patients. Six patients underwent bilateral reimplanta-tion, resulting in a total of 23 ureters repaired. There were 16 females and 1 male (mean age6.23 years). Four patients had prior Deflux injection. Postoperative reflux status was assessedby voiding cystourethrogram.Results: 16 patients (22 ureters) were compliant with follow up. Mean follow up was 11.5months. Mean anesthetic time was 3 h, 57 min for unilateral and 4 h, 45 min for bilateralrepair. Complete vesicoureteral reflux resolution was seen in 20 ureters (90.9%), downgradingin one ureter, and unchanged persistent reflux in one ureter. Average hospital stay was 1.3days. No patients required postoperative catheterization at discharge.Conclusions: Outcomes for new procedures can be variable and unpredictable as the techniqueevolves. Given the high success rates of open reimplantation, a minimally invasive techniquemust show comparable results if it is to play a continuing role. Our initial results are encour-aging, but prospective analyses are required to outline the future role of RAL ureteral reim-plantation.ª 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

545 9520; fax: þ1 860 545 9545.ent.uchc.edu (D. Chalmers), kherbst@ccmckids.org (K. Herbst), ckim@ccmckids.org (C. Kim).

iatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Robotic-assisted laparoscopic extravesical ureteral reimplantation 269

Introduction

Vesicoureteral reflux (VUR) continues to be a prevalentdisorder treated by pediatric urologists. Although the trueincidence is unknown, VUR has been reported in up to 30%of children who have had at least one urinary tract infec-tion (UTI). UTIs occur in 2%e8% of children younger than 10years old [1,2]

Surgical correction of VUR aims to prevent the associ-ated risk of pyelonephritis and subsequent renal scarring.There are many available options, including endoscopicinjection therapy, open ureteral reimplantation, andminimally invasive ureteral reimplantation.

Open ureteral reimplantation continues to be the goldstandard of surgical intervention [3]. However, promisingresults have been demonstrated by minimally invasivetechniques. There are multiple possibilities for minimallyinvasive ureteral reimplantation, including laparoscopic orrobotic-assisted laparoscopic (RAL) approaches. The repaircan be performed intravesically or extravesically with bothstandard laparoscopy and RAL [4e7]. Purely laparoscopicreconstructive surgery can be technically challenging, evenfor experienced laparoscopic surgeons.

The robotic platform allows improved dexterity,provides three-dimensional visualization, and downscalesmotion. Additional advantages over pure laparoscopyand open surgery are the improved visualization with10� magnification and the ergonomic ease for the surgeonat the robotic console.

Historical success rates for open reimplantation are95e99%. Therefore, minimally invasive correction mustmeet similarly high standards when comparing results.Initial attempts at laparoscopic reimplantation have yiel-ded success rates as high as 91% [8]. Reports of RAL ureteralreimplantation have also shown a high success rate of 97.6%[4]. These results are promising, but it remains to be seen ifthey are reproducible and sustainable. We believe furtheranalysis is warranted from multiple institutions whenassessing overall efficacy of a new treatment modality.

Therefore, we reviewed our initial experience withunilateral and bilateral extravesical reimplantation usinga robotic approach. Our goal was to determine the overallsuccess and complication rates in our case series. We hopethese data will help define the emerging role of RALureteral reimplantation in pediatrics.

Materials and methods

After obtaining IRB approval at our institution,we performeda retrospective chart review of all patients who underwentrobotic-assisted extravesical reimplantation at ConnecticutChildren’s Medical Center between October 2007 and May2010. The technique for reimplantation has been describedelsewhere previously [4]. A total of 17 patients underwentRAL ureteral reimplantation by a single surgeon afterextensive counseling regarding various treatment options.This method of repair was chosen by the family afterextensive counseling regarding various treatment options,including observation, Deflux injection, and open ureteralreimplantation. Eleven cases were unilateral reimplants andsix were bilateral. A total of 23 ureters underwent

reimplantation. We reviewed patient demographics (Table1), indications for surgery, operative and hospital courses,and grading of reflux both before and after surgery.

The mean age at surgical intervention was 6.23 years old(þ/�3.4 years). The mean surgical weight was 24.9 kg(þ/�17.9). Sixteen patients were female and one patientwas male.

Follow up data were available for 16 patients with anaverage follow up of 11.5 months. The indications forsurgery included recurrent febrile UTI (64.7%), noncompli-ance with antibiotics (11.8%), renal scarring (11.8%), andparental preference (11.8%). The preoperative grade ofreflux was grade I (4%), grade II (26%), grade III (57%), andgrade IV (13%). Four of seventeen patients had Defluxsurgeries for VUR prior to surgery.

A renalultrasoundwasperformed1monthpostoperativelyand voiding cystourethrogram was performed 3 monthspostoperatively. One patient was noncompliant with followup resulting in imaging results on 16 patients (22 ureters).

Results

Six patients underwent bilateral repairs. Robotic time wason average 57 min longer for the bilateral repairs. Robotictime was calculated as time from docking the machine toundocking the machine.

The mean anesthesia time for unilateral repair was 3 h57 min (range: 3 h 34 min to 4 h 37 min). The mean anes-thesia time for bilateral repair was 4 h 45 min (range 4 h31 e5 h 35 min). The mean robot time for unilateralreimplantation was 2 h 7 min (range 1 h 45 mine2 h 35 min).The mean robot time for bilateral reimplant was 2 h 57 min(range 2 h 40 mine3 h 20 min).

There were no violations into the mucosal layer duringdissection. In the four patients with prior Deflux injection,blebs of Deflux material were seen intraoperatively, but thisdid not alter the operation and no postoperative complica-tions were seen in these patients. In this subset population,themean anesthesia time was 4 h 4min. We did not feel thatpreoperative Deflux injection was a contraindication orimpedance to RAL extravesical ureteral reimplantation.

Although it was not required, we elected to leavea Foley catheter in the first two patients. Both patients hadthe catheter removed on postoperative day 1. In our series,there were no patients with urinary retention. Averagehospital stay was 1.3 days (SD þ/�0.48 days). There wereno intraoperative complications. New contralateral grade Ireflux was observed in one patient.

One patient in this cohort had preoperative moderatehydronephrosis, which resolved postoperatively. We sawcomplete resolution of reflux in 14 patients (87.5%) and 20ureters (90.9%). There was downgrading of reflux fromgrade IV to grade I in one patient, and this patient’srecurrent UTIs resolved. One patient with bilateral grade IIIreflux achieved complete resolution on one side but hadpersistent grade III reflux on the other side, which wassuccessfully managed with a subsequent Deflux injection.All four patients who received prior Deflux proceduresachieved complete resolution of reflux. Of the 16 patientswith follow up information available, none reported anysymptoms on follow up.

Table 1 Description of Study Population.

Demographic information (n Z 17).

Type of Repair % (n) Primary Indication % (n)Unilateral 62% (11) Recurrent UTI 64.7% (11)Bilateral 38% (6) Non-compliance 11.8% (2)

Length of Stay Renal scarring 11.8% (2)1 Day 71% (12) Parental preference 11.8% (2)2 Days 29% (5)

Prior Surgeries Mean (þ/�SD)Failed Deflux 23.5% (4) Age at Surgery 6.25 (þ/�3.4) yearsNone 76.5% (13) Weight at Surgery 27 (þ/�18) kg

270 D. Chalmers et al.

Discussion

When choosing a management strategy for VUR, parentsand the patient can be overwhelmed in making an informeddecision. Even when surgery is chosen, there is thecontinued challenge of choosing the best surgical approachfor that individual. In guiding those decisions, we mustcarefully counsel our patients regarding the risks, benefits,and expected results from surgery.

The application of robotic surgery for children is currentlyexpanding. RAL ureteral reimplantation has the potential toprovide patients with a highly successful repair with minimalmorbidity. The primary goal of the surgery remainsunchanged when compared to open techniques: recreatinga longer detrusor tunnel to eradicate reflux. Using wristed,fine instrumentation and improved magnification, roboticsurgery should ideallyminimize blood loss aswell asmuscularand neural disruption to the detrusor [4]. Although techni-cally demanding, potential benefits include reduced pain,improved cosmesis, and rapid Foley catheter removal.

Although some case series have shown impressive resultswith RAL ureteral reimplantation, we must continue toanalyze the data with a discerning eye. Even pioneers ofpediatric robotic surgery advise caution and close scrutinyof future results [9]. Our series of patients is small, but itsupports the belief that RAL extravesical ureteral reim-plantation is safe and effective. With a resolution rate of90.9% ureters, we are encouraged to continue our explo-ration of this surgical technique. Although our reportedcomplete resolution rate is lower than that reported inopen series, it is encouraging and may reflect an initiallearning curve. We were pleased that none of our patientsreported adverse symptoms in follow up and there were noperioperative complications, and all patients experiencedresolution of their symptoms. We did observe persistentgrade III reflux in one patient who underwent bilateralreimplantation for bilateral grade III reflux. This persistentreflux resolved after an additional Deflux injection. We alsoobserved new grade I reflux in a contralateral unit in onepatient. Our patients were able to leave the hospital in 1.3days, which is shorter than the 2 days patients typically stayfollowing open ureteral reimplantation.

The primary limitation of our study is its small size, whichprevents any definitive conclusions regarding the efficacy ofour robotic technique. Larger prospective studies frommultiple institutions are required before identifying the roleof RAL reimplantation in the management of VUR. Although

our success rate is lower than some reports, the literature isstill very new and small in volume. Therefore, we feel a truebenchmark of success is not yet established for this tech-nique. We believe the most likely cause of failure is makingthe extravesical tunnel too short. To improve exposure, weoften use a hitch stitch through the anterior bladder wall.The stretch created by this stitch may overestimate the truetunnel length.

There are also limitations regarding the robotic platformitself. Robotic-assisted surgery lacks haptic feedback.However we believe that this concern is alleviated by thethree-dimensional vision, improved magnification and theability to see from multiple angles. Opponents of roboticsurgery also cite the substantial initial investment and highmaintenance costs as evidence that robotic surgery isirresponsible in an era of spiraling healthcare costs [7].Interestingly, the pioneers of laparoscopy experiencedsimilar limitations nearly 20 years ago. There is alsoa substantial learning curve inherent to any new technique,which we believe is reflected in prolonged operative timescompared to traditional open surgery. Our robotic opera-tive time appeared to be trending down when we comparedthe first five patients to the final five; however, our series istoo small to demonstrate statistical significance. It remainsto be seen whether advantages such as decreased bloodloss, reduced pain, improved cosmesis, and shorter hospitalstay outweigh the additional cost of robotic surgery.Comparable outcomes to open surgery must be demon-strated before it can be an established alternative.

Conclusions

Robotic extravesical reimplantation is still a new surgicalapproach to VUR, but it appears promising in terms ofsafety and efficacy. Future investigation of the techniquewith larger patient populations is required to bettercompare results with the gold standard of open repair.

Funding

None declared.

Conflict of Interest

None declared.

Robotic-assisted laparoscopic extravesical ureteral reimplantation 271

Appendix A. Supplementary material

Supplementary video related to this article can be found, inthe online version, at doi:10.1016/j.jpurol.2011.04.006.

References

[1] Stansfeld J. Clinical observations relating to incidence andaetiology of urinary tract infections in children. Br Med J 1966;5488:631e5.

[2] Windberg J, Anderson HJ, Berstrom T, Jacobsson B, Larson H,Lincol K. Epidemiology of symptomatic urinary tract infectionin childhood. Acta Paediatr Scand 1974;252:1e20.

[3] Paquin AJJ. Ureterovesical anastomosis: the description andevaluation of a technique. J Urol 1959;82:573e83.

[4] Casale P, Patel RP, Kolon TF. Nerve sparing robotic extravesicalureteral reimplantation. J Urol 2008;179:1987e9. discussion 1990.

[5] Lakshmanan Y, Fung LC. Laparoscopic extravesicularureteral reimplantation for vesicoureteral reflux: recenttechnical advances. J Endourol 2000;14(589e93):593e4.discussion.

[6] McDougall EM, et al. Laparoscopic repair of vesicoureteralreflux utilizing the Lich-Gregoir technique in the pig model.J Urol 1995;153:497e500.

[7] Thakre AA, Yeung CK. Technique of intravesical laparoscopyfor ureteric reimplantation to treat VUR. Adv Urol; 2008:937231.

[8] Canon SJ, Jayanthi VR, Patel AS. Vesicoscopic cross-trigonalureteral reimplantation: aminimally invasive option for repair ofvesicoureteral reflux. J Urol 2007;178:269e73. discussion 273.

[9] Peters CA. Robotically assisted surgery in pediatric urology.Urol Clin N Am 2004;31:743e52.