Efficacy of robot-assisted laparoscopic ureteral reimplantation for primary obstructive megaureter in children / 中华泌尿外科杂志

ABSTRACT

Objective To evaluate the clinical efficacy of robot-assisted laparoscopic ureteral reimplantation (RAUR) for primary obstructive megaureter (POM) in children.Methods Twenty-one patients who underwent RAUR for POM in Bayi Children's Hospital between 2017 April and 2018 April were retrospectively analyzed.The study population consisted of 15 boys and 6 girls aged between 2 months and 11 years.Ten patients had left POMs,9 had right POMs and two had bilateral POMs.All patients were preoperatively diagnosed with a POM based on urinary system ultrasonography,magnetic resonance urography,and diuretic renal dynamic imaging.Our main technique key steps includeUnder general anesthesia,the patients were placed in a Trendelenburg position approximately 40 degrees from the horizon.An 8.5-mm camera port was placed at the level of the umbilicus.Followed by two 5-mm robotic Trocars placed under direct vision 6 cm to the camera port separately,a 5-mm assistant port was placed on the right upper abdominal quadrants which was located 3 cm from the camera and robotic port.The ureter was identified at the pelvic brim.The peritoneum covering the ureter was incised and the ureter was mobilized to the level of the vesico-ureteric junction.The bladder was filled with 60 ml saline and a 5 cm length and 1.5 cm wide submucosal detrusor tunnel was created.The ureter was transected at the bladder mucosa and the narrowed ureteral segment was discarded.The ureteroneocystostomy was performed using 6-0 absorbable suture.Dissecting the perivesical fascia appropriately and using down-top suturing approach,use of an apical stay stitch,and incorporation of the ureteral adventitia during detrusorraphy.Postoperative complications were analysed using the Clavien-Dindo classification.Success was defined as symptomatic relief,decreased hydronephrosis on ultrasound and no evidence of vesicoureteral reflux on voiding cystourethrography.Results All surgeries were successfully completed without conversion and no intra-operative complication was encountered.The mean operative time was 117.6 ± 18.1 (89-165)min,the mean estimated blood loss was 11.9 ± 4.3 (5-25) ml,the abdominal drainage tubes were removed after a mean of 4.9 ± 1.1 (3-8) days,and the mean postoperative hospital stay was 6.3 ± 1.3(4-10) days.Postoperative complications (Clavien Ⅰ-Ⅱ) occurred in 9.5％ (two patients had recurrent urinary tract infections postoperatively) children,no grade Ⅲ-Ⅳ complication was observed.The pre-operative symptoms in all patients disappeared.One patient had grade Ⅱ VUR on VCUG,who were followed conservatively.Ultrasound at postoperative follow-up showed that the hydronephrosis was disappeared in 20 ureters and significantly decreased in 3 ureters.The success rate was 95.7％ at a mean follow-up of 16.3 ± 4.0 (10-23) months.Conclusion RAUR is a safe and feasible option for the treatment of POM in children with higher success rate and lower complication rate.